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DRAFT DAFTAR FORMULARIUM

RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
I. OBAT ANTI SISTEM GASTROINTESTINAL & HEPATOBILIER ALKOHOL 70% 1 LTR Onemed
Alkohol Swab Onemed
A. ANTASIDA Ac swab 2% Onemed
Sodium Bicarbonat 1 Sodium Bicarbonat Generik Tablet 500 mg

Mg(OH) + Al(OH)3 1 Antasida Generik Tablet Erela


Syrup 60 ml

Metilpolisiloksan, MgOH,Al(OH) 1 Polycrol Forte Syrup Nicolas

Mg(OH) + Al(OH)3 + simeticon 1 Acitral Syrup Interbat


Tablet
3 Magalat Susp Ferron
4 Magtral Susp Otto
Tablet

Sucralfate 1 Impepsa Susp Fahrenheit


2 Mucin Susp 120 cc & 60 cc Otto
3 Molafat Susp 60 cc Molex Ayus
4 Ulsafat Susp 100 cc & 200 cc Combiphar

Rebemipide 1 Mucosta Tablet 100 mg Eisai


2 Novepide Tablet 100 mg Novell
3 Sysmuco Tablet 100 mg Fahrenheit

Fucoidan 1 Fucohelix Tablet 100 mg Kalbe Farma


2 Fucoidan 100 Tablet 100 mg Soho

B. ANTI REFLUK DAN ANTI ULSERASI


Ranitidin 1 Ranitidin Generik Injeksi Hexpharm
Tablet 150 mg Hexpharm
2 Acran Injeksi 150 mg Sanbe
3 Gastridin Injeksi 150 mg Interbat
Tablet 150 mg
4 Ranicare sirup Nicolas
5 Rantin Injeksi 150 mg Kalbe Farma
Tablet
Omeprazole 1 Omeprazole Generik Capsul 20 mg nulab
Injeksi Bernofarm
2 Ozid Injeksi 20 mg Darya Varia
3 Protop Capsul 20 mg Interbat
4 Rocer Capsul 20 mg Otto
5 Pumpitor Injeksi 20 mg Sanbe

Lansoprazole 1 Lansoprazole Generik Capsul 30 mg Hexapharm


3 Inhipraz Capsul 30 mg Bernofarm
4 Lancid Capsul 30 mg Kalbe Farma
5 Prazotec Capsul Fahrenheit

Pantoprazol 1 Pantoprazol Generik Capsul Hexpharm


Injeksi Bernofarm
2 Caprol Injeksi Ethica
3 Pranza Injeksi Kalbe Farma
4 Vomizol Injeksi Dexa Medica

Esomeprazol 1 Nexium Kapsul 20 mg, 40 mg AstraZeneca


Injeksi 40 mg

Misoprostol 1 Gastrul Tablet Fahrenheit


2 Invitec Tablet Kalbe Farma
3 Noprostol Tablet Vagina Novell
C. GIT REGULATOR, ANTI FLATULEN, DAN INFLAMASI
Sulfasalazine 1 Sulcolon Tablet 500 mg Bernofarm

Budesonide 1 Budenofalk Capsul 3 mg Darya Varia

Lactobasilus Acidophilus 1 Lacto B Sachet Novell

1
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
2 Lacidofil Capsul Dexa Medica
3 Liprolac Sachet Kalbe Farma
4 Interlac Drop Interbat

D. ANTI SPASMODIK
Hyoscine_N_Butylbromide 1 Buscopan Tablet 10 mg Tempo
injeksi
2 Buscopan Plus Tablet Boehringer

Hyoscine N B + Paracetamol 1 Scopamin Plus Tablet Otto


2 Gitas plus injeksi Interbat
Tablet

Clinidium Br + Chlordiazepoxid 1 Renagas Tablet Fahrenheit


2 Librax Tablet Combiphar
3 Braxidin Tablet Sanbe

Otilonium Bromida 1 Spasmomen Tablet Dexa Medica

E. ANTI DIARE
Attapulgit Aktif Koloid 1 Diadium Tablet 2 mg Lapi

f 1 Antidia Tablet 2 mg Berno


2 Loperamid Generik Tablet

Kaolin Pectin 1 Molagit Tablet 600 mg Molex ayus

F. LAKSATIF PENCAHAR
Laktulose 1 Lactulax Syrup 200 ml Ikapharm
2 Constipen Syrup 120 ml Combiphar
3 Dulcolactol Syrup Boehringer

Bisacodyl 1 Dulcolax Tablet Boehringer


Suppos 5 mg,10 mg Boehringer

Paraffin Gliserin 1 Laxadine Syrup Gelenium

Sorbitol + Na Lauril Sulfat 1 Microlax Suppos 5 mg,10 mg Pharos


2 Laxoberon Drop Boehringer
3 Laxarec Supp Gelenuim

G. DIGESTAN
Amilase, Protease, Vit Bpleks 1 Enzyplex Tablet Darya Varia
2 Enzymfort Tablet Kimia Farma

Pankreatin 1 Pankreoflat Tablet Kimia Farma


2 Gasflat Tablet Fahrenheit

H. KOLAGOGUM, KOLELITOLITIK, DAN HEPATOPROTEKTOR

Ursodeoxycholic 1 Urdafalk Tablet 250 mg Darya Varia


2 Urdahex Capsul Kalbe Farma
Syrup

Lecithin + Vit Bpleks 1 Lesichol Capsul 300 mg/ 600 mg Landson


2 Lesifit Capsul Sandoz

Curcuminoid + Silmarine + Coline 1 Proliver Tablet Simex


2 Biocurliv Tablet Soho
3 Hepamax Kaplet Kalbe Farma

L-ornitin-L-Aspartat 1 Hepa-Merz Sachet Granul Combiphar


Injeksi
1 Forheva Injeksi Kalbe Farma

Neo Mino Phangen C 1 SNMC Injeksi Dexa Medica

Selenium + Bioflavonoids + lipoic acd 1 Livapro SS Capsul Novell

2
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
2 Proliva Kaplet Gracia

Palecatechu + Curcumin 1 Rejuvit Capsul Nutrindo

I. PREPARAT ANOREKTAL / ANTI HEMOROID


Anti hemoroid 1 Anti hemoroid Generik Suppos kimia farma

Fluocortolon + Lidocain 1 Ultraproct N Suppos Schering


Salep

Lithospermi+Benzokain+Difenhidram 1 Borraginol - N Suppos Takeda

Sda + Prednison 1 Borraginol - S Suppos

Hydrosmin 1 Venosmil Gel 60 gr Kalbe Farma

Citrus Bioflavonoid+diosmin 1 Ardium HD Tablet 500 mg Servier


2 Ciflon Kaplet Lapi

J. ANTIEMETIK
Domperidone 1 Domperidone Generik Tablet 10 mg Nulab
Syrup Bernofarm
2 Vometa Syrup 60 ml Dexa Medica
Tablet 10 mg
Drop
3 Motilium Tablet 10 mg Jansen
4 Vosedon Syrup Sanbe
5 Nomesis Drop Bernofarm

Metoclorpramide 1 Metoclorpramide Generik Tablet 10 mg


Injeksi 10mg/2ml
2 Metolon Tablet 5 mg, 10 mg Berno
Injeksi 10 mg/2 ml
3 Sotatic Tablet 10 mg Fahrenheit
Injeksi 5 mg/ml, 2 ml
4 Piralen Injeksi 10 mg/2 ml Otto

Dimenhidrinate 1 Dimenhidrinate Generik Tablet

Piradhiazine+Chloropheophylinate+Vit. B6 1 Anvomer B6 Tablet Dexa Medica

Ondansentron 1 Ondansentron Generik Injeksi 4 mg, 8 mg Dexa


Tablet 4 mg, 8 mg Nulab
2 Kliran Injeksi 4 mg, 8 mg Bernofarm
3 Invomit Tablet 4 mg, 8 mg Interbat
Injeksi 4mg/2ml
4 Cedantron Injeksi Soho

K. OBAT GASTROINTESTINAL LAIN


Lyophilized cyclic - somatostatin 1 Somatostatin Lyomark Injeksi 250 mcg/3 mg Combiphar
2 Somatostatin Eumedica Injeksi 250 mcg/3 mg Dexa Medica

II. SISTEM KARDIOVASKULER DAN HEMATOPOITIK

A. OBAT JANTUNG
Digoxin 1 Digoxin Generik Tablet 0.25 mg Indofarma
2 Fargoxin Tablet 0.25 mg Fahrenheit
Injeksi 0.5 mg/2 ml

Dobutamin HCl 1 Dobuject Injeksi 250 mg Dexa Medica

Dopamin HCl 1 Dopamin Giulini Injeksi Kimia Farma

Amiodaron HCl 1 Kendaron Injeksi 150 mg / 3ml Darya Varia

3
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
2 Tiaryt Tablet 200 mg Fahrenheit

Profapenon HCl 1 Rhytmonorm Tablet 150 mg Abbott

B. OBAT ANTI ANGINA


Isosorbidedinitrate 1 Isosorbidedinitrate Generik Tablet 10 mg kimia farma
2 Farsorbid Tablet 5 & 10 mg Fahrenheit
3 Cedocard Tablet 5 & 10 mg Darya Varia
Injeksi 10 mg / 10 ml

Diltiazem 1 Diltiazem Generik Tablet 30 & 60 mg Dexa


2 Herbesser Injeksi Tanabe

3 Herbesser CD Tablet 100 & 200 mg Tanabe

4 Farmabes Injeksi 5 mg/ml, 5 ml Fahrenheit


Tablet
5 Cordila SR Tablet 180 mg Dexa Medica

Amlodipine besylate 1 Amlodipine Generik Tablet 5 & 10 mg Kimia Farma


2 Lovask Tablet 10 mg Bernofarm
3 Intervask Tablet 5 mg, 10 mg Interbat
4 Tensivask Tablet 10 mg Dexa Medica
5 Theravask Tablet 5 & 10 mg Darya Varia

C. ACE - INHIBITOR
Captopril 1 Captopril Generik Tablet 12,5. 25. 50 mg Dexa
2 Captensin Tablet 12,5. 25. 50 mg Kalbe Farma

Ramipril 1 Ramipril generik Tablet 5 mg Dexa


2 Hyperil 5 mg Tablet 5 mg Ferron

Lisinopril 1 Interpril Tablet 5 mg, 10 mg Interbat

Imidapril HCl 1 Tanapres Tablet 10 mg Tanabe

Enalaprilmaleate 1 Renacardon Tablet 5 mg, 10 mg Fahrenheit

Perindopril 1 Bioprexum Tablet 5 mg Servier

D. PENYEKAT BETA
Bisoprolol 1 Bisoprolol Generik Tablet 5 mg Dexa
2 Concor Tablet 5 mg Merck
3 Maintate Tablet 5 mg Merck
4 Bisovell Tablet 5 mg Novell

Propanolol 1 Propanolol Generik Tablet 10 & 20 mg Hexpharm


2 Farmadral Tablet 10 mg Fahrenheit

Atenolol 1 Farnormin Tablet 50 mg Fahrenheit

Nebivolol 1 Nebilet Tablet 5 mg Dexa Medica

E. ANTAGONIS KALSIUM
Nifedipin 1 Nifedipin Generik Tablet 10 mg Dexa
2 Adalat Oros 30 mg Bayer

Verapamil 1 Isoptin SR Tablet 240 mg Abbott

Nicardipine HCl 1 Perdipine injeksi Injeksi 10 mg / 10 ml Astellas


2 Carsive Injeksi 10 mg / 10 ml Landson

F. ANTAGONIS ANGIOTENSIN II
Candesartan cilexetil 1 Candesartan Generik Tablet 8mg, 16 mg Dexa Medica
2 Blopress Tablet 8mg, 16 mg Takeda
3 Canderin Tablet 8mg, 16 mg Dexa Medica

4
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus

Losartan K 1 Losartan Generik Tablet 50 mg Hexpharm


2 Insaar Tablet 50 mg Interbat
3 Lifezar Tablet 50 & 100 mg Darya Varia

Irbesartan 1 Iretensa Tablet 150 mg Fahrenheit


2 Irvask Tablet 150 mg Kalbe Farma

Olmesartan 1 Olmetec Tablet Pfizer

Telmisartan 1 Micardis Tablet 40 mg Boehringer

H. OBAT HIPERTENSI KOMBINASI


Amlodipine besylate+valsartan 1 Exforge Tablet 5/80 mg, 5/160 mg Novartis

Amlodipine besylate + Atorvastatin Ca 1 Caduet Tablet Pfizer

Perindopril + Amlodipine 1 Coveram Tablet 5/5 mg, 5/10 mg Servier

Valsartan + HCT 1 Co-Diovan Tablet 80/12.5 mg Novartis

Telmisartan + Amlodipine 1 Twynsta Tablet 40/5 mg Boehringer

I. ANTI HIPERTENSI GOLONGN LAIN


Clonidine 1 Clonidine Generik Tablet 75/150 mcg
2 Catapres Tablet 75/150 mcg Boehringer
injeksi 150 mg

Methyldopa 1 Dopamet Tablet 250 mg Actavis

J. DIURETIK
Furosemid 1 Furosemid Generik Tablet 40 mg
2 Farsix Tablet 40 mg Fahrenheit
Injeksi 20 mg / ml
3 Lasix Tablet 40 mg Aventis
Injeksi 20 mg / ml

Hydrochlorthiazide 1 HCT Generik Tablet 25 mg

Spironolactone 1 Spironolactone Generik Tablet 100 mg


2 Carpiaton Tablet 100 mg Fahrenheit

Manitol 1

K. VASODILATOR PERIFER DAN AKTIFATOR SEREBRAL


Citicholine 1 Citicholine Generik Tablet 500 mg Hexpharm
Injeksi 250 & 500 mg
2 Braint act Tablet 500 mg Kalbe Farma
Sachet 1000 mg
Injeksi 500 mg
3 Incelin Tablet 500 mg Interbat
Injeksi 250 mg, 500 mg, 1000 mg
4 Lancolin Tablet 500 mg,250 mg Landson
Injeksi 500 mg

Nimodipin 1 Nimotop Injeksi 10 mg/50 ml Bayer

fosfatidil serin 1 Memoran Capsul 100 mg Soho

Ginkgo biloba 1 Tanakan Tablet Combiphar

L. VASOKONSTRUKTOR
Nor Epinephrin 1 Raivas Injeksi 4 mg Dexa Medica
2 Vascon Injeksi 4 mg Fahrenheit
3 Nor epineprin generik Injeksi 4 mg

M. OBAT DISLIPIDEMI

5
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
Simvastatin 1 Simvastatin Generik Tablet 10mg, 20mg Berno
2 Mersivas Tablet 10 mg Mersi

Ca-Rosuvastatin 1 Crestor Tablet Astra

Fenofibrate 1 Lipanthyl Tablet 200mg Combiphar


2 Fibramed Tablet 300 mg Promed
3 Yosenob Tablet 300 mg Nufarindo

Ca-Atorvastatin 1 Lipitor Tablet 10mg, 20mg Pfizer


2 Atorsan Tablet 10mg, 20mg Sandoz

Atorvastatin 1 Atorvastatin Generik Tablet 10 mg Dexa Medica


2 Stator Tablet 20mg Dexa Medica
3 Truvas Tablet 10mg Kalbe Farma

Gemfibrozil 1 Gemfibrozil Generik Tablet 300 mg


2 Lipitrob Tablet 600 mg Tropicamas

Simvastatin + Ezetimibe 1 Vytorin Tablet 10/10 mg MSD

N. HEMOSTATIK
Asam tranexamat 1 Kalnex Tablet 250 mg & 500 mg Kalbe Farma
Injeksi 250 mg & 500 mg
2 Transamin Injeksi 250 mg & 500 mg Otto
Tablet 250 mg & 500 mg
3 Internic Injeksi 250 mg Interbat

4 Asam Tranxamat generik Tablet 250 mg & 500 mg Bernofarm


injeksi 250 mg & 500 mg Dexa

Carbazochrome sodium sulfonat 1 Adona AC Injeksi 25 mg & 50 mg Tanabe


Tablet 10 mg
2 Crome Injeksi 50 mg Ferron
Tablet 10 mg

Vitamin K 1 Menadione Tablet 10 mg Kimia Farma


Injeksi 10 mg
2 Neo K Injeksi Combi
3 Vitamin K injeksi Rajawali

O. ANTI KOAGULAN, ANTI PLATELET DAN FIBRINOLITIK


As. Asetilsalisilat 1 Aspilet Tablet 80 mg UAP
2 Ascardia Tablet 80mg,160mg Pharos
3 Thrombo Aspilet Tablet Medifarma

As. Asetilsalisilat + Glycine 1 Proxime Tablet Sanbe

Ticlopidin HCl 1 Cartrilet Tablet 250 mg Fahrenheit

Cilostazol 1 Pletaal Tablet 100mg Otsuka


2 Citaz Tablet 50mg Dankos

Streptokinase 1 Streptase Injeksi 1.500.000 IU Dexa Medica

Parnaparin 1 Fluxum Injeksi 0,4 . 0,6 cc Fahrenheit

Enoxaparin Na 1 Lovenox Injeksi 0.2, 0.4, 0.6 cc Sanofi

Fondaparinux Na 1 Arixtra Injeksi 2.5 mg Glaxo

Clopidogrel 1 Clopidogrel Generik Tablet 75 mg Dexa


2 Pladogrel Tablet 75 mg Fahrenheit
3 Clogin Tablet 75 mg Interbat

Dabigatran etexillate 1 Pradaxa Capsul 75 mg & 150 mg Boehringer

6
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus

Fibrinolisin + Profibrinolisin aktifator 1 Plasmin Capsul 250 mg Landson

Nattokinase + Q10 1 Natto-10 Tablet Lapi

Nattokinase+Bromelain+Papain+Bioflavonoid 1 Fibrinase Kapsul Escolab

Warfarin Na 1 Simarc-2 Tablet 2 mg Fahrenheit

P. OBAT PLEBITIS/VARISES
1 Thrombophob Gel 20 gr Tunggal I.A

Q. HEMATOPOIETIK
-

III. SISTEM PERNAPASAN

A.OBAT ANTI ASMA DAN PPOK


Theophylline 1 Bronchophyllin Syrup 100 cc 150 mg/15 ml Darya Varia

Theophylline Anhidrous 1 Euphyllin R Tablet 250 mg Pharos


2 Euphyllin Retard Mite Tablet 125 mg Pharos

Terbutalin Sulfat 1 For Asma Tablet 2.5 mg Guardian


2 Theobron Syrup Interbat
Caps

Salbutamol 1 Salbutamol Generik Tablet 2 mg & 4 mg Kimia Farma


Syrup
2 Lasal Syrup 2 mg / 5 ml LAPI
3 Astharol Syrup Sanbe

Efedrin HCl 1 Efedrin HCl Generik Tablet 25 mg


Injeksi 50 mg/ml

Procaterol HCl 1 Ataroc Syrup 25 mcg Novell


2 Meptin Tablet 50 mcg Otsuka
3 Meptin swing heler Spray 10 mcg/dosis Otsuka

Budesonide+Formoterol 1 Symbicort Turbo Heler Inhaler 60 dosi 80/4.5 &160/4.5 AstraZenica

Salmeterol+Fluticasone 1 Seretide Spray Inhaler 125 mcg Glaxo


1 Seretide Discus Inhaler 500 mcg Glaxo

Salbutamol 1 Ventolin Inhaler Glaxo


Nebuls
Ipatropium+Salbutamol 1 Combivent Nebuls 0.5mg/2.5mg Boehringer
2 Farbivent Nebuls 0.5mg/2.5mg Fahrenheit

Flucitasone Propionat 1 Flixotide Nebuls Glaxo

Budesonide 1 Pulmicort Nebulizer AstraZenica

B. OBAT BATUK DAN PILEK


Ambroxol 1 Ambroxol Generik Tablet 30 mg Kimia Farma
Syrup 60 ml
2 Molapect Syrup 15mg/5ml Molex ayus
Tablet 30 mg
3 Interpect Tablet 30 mg Interbat
Eliksir
4 Mucos Drop 20 ml Meprofarm
Syrup 60 mg

Bromhexin HCl 1 Bisolvon Tablet 4 mg& 8 mg Boehringer


Injeksi 2mg/ml
2 Mucohexin Tablet 8 mg Sanbe
Eliksir 120 ml

7
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
Dextrometrophan 1 Dextrometrophan Generik Tablet 15 mg Kimia Farma
Syrup 60 ml

Glyceril Guaiacolat 1 Glyceril Guaiacolat Generik Tablet


2 OBH Generik Syrup Molex ayus

N-Acetylcysteine 1 Fluimucil Eff Tablet 600 mg Zambon


1 Simucil Capsul 200 mg Mersifarma

Erdostein 1 Edotin Capsul 300 mg Ferron


2 Vestein Syrup 175 mg/5 ml Kalbe Farma
Capsul 300 mg
3 Vectrin Syrup 175 mg/5 ml Dexa Medica
4 Mucotein Capsul 300 mg Combiphar
5 Mucotein DS Syrup 175mg/5 ml

Obat Batuk Kombinasi 1 Comtusi Syrup 60 ml Combiphar


2 Sanadryl Syrup Sanbe
3 Lapisiv Syrup Lapi
4 Dextral Tablet Molex Ayus
Syrup

Obat Batuk Kombinasi+Paracetamol 1 Alpara Tablet Molex Ayus


Syrup

Loratadin+Pseudoepedrin 1 Aldisa SR Capsul Sanbe


2 Rhinos SR Capsul Dexa Medica
3 Rhinos Neo Drop Dexa Medica
4 Rhinos Junior Syrup Dexa Medica

Tripolidin+Pseudoepedrin+Dextro 1 Lapifed DM Syrup Lapi

Tripolidin+Pseudoepedrin 1 Tremenza Tablet Sanbe


Syrup
2 Trifed Tablet Interbat
Syrup

Pseudoepedrin 1 Alco Drop Interbat

Pseudoepedrin + DMP 1 Alco syrup Interbat

Tervenadine+Pseudoepedrin 1 Rhinofed Tablet Dexa Medica

Fexofenadine+Pseudoepedrin 120 1 Fexofed Tablet Kalbe Farma

Troxerutin+Zn Gluconat 1 Coldizo Tablet isap Soho

Codein 1 Codein Tablet 30 mg Kimia Farma


2 Codipront Tablet 30 mg Kimia Farma
Syrup
Codein+GG 1 Codipront Cum Expect. Tablet Kimia Farma
Syrup
Noscapine 1 Levopront Syrup 60 ml Combipharm
2 Longatin Capsul Alpharma

IV. SISTEM SARAF PUSAT


A. ANSIOLITIK
Diazepam 1 Diazepam generik Tablet 5mg, 10mg
2 Valisanbe Tablet 5 mg Sanbe
3 Stesolid Injeksi 10 mg Actavis
Suppos 5mg, 10mg
4 Valium Tablet 5 mg Roche
Injeksi 10 mg/ 2 ml

Alprazolam 1 Alprazolam Generik Tablet 1mg, 0.5mg Dexa


2 Feprax Tablet 0,5mg Ferron
3 Xanax Tablet 1mg, 0.5mg Pfizer
4 Zypraz Tablet 0.5 mg Kalbe Farma

8
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus

Clobazam 1 Clobazam Generik Tablet 10mg

Lorazepam 1 Ativan Tablet 1mg, 2mg Sunti S

Bromazepam 1 Lexotan Tablet 1.5mg , 3mg Roche

D. HIPNOTIK SEDATIV
Zolpidem Tartrat 1 Zolmia Tablet 10 mg Fahrenheit

Midazolam 1 Dormicum Injeksi 5 mg/5 ml Roche

E. ANTI DEPRESAN
Sertralin 1 Deptral Tablet 50 mg Meprofarm
2 Serlof Tablet 50 mg Kalbe Farma
3 Nudep Capsul 50 mg Guardian

Fluoxetine HCl 1 Kalxetin Capsul 10 mg, 20 mg Kalbe Farma

Maprotiline HCl 1 Tilsan Tablet 25 mg Otto

Tianeptine 1 Stablon Tablet 12.5 mg Servier

Clomipramine 1 Anafranil Tablet 25 mg Novartis

Neuravena 1 Nurest Capsul 350 mg Nulab

G. ANTI KEJANG
Phenobarbital 1 Phenobarbital Generik Tablet 30 mg
2 Phental Injeksi Combiphar
Phenobarbital+Pipenzolate+Ethanol 1 Piptal Drop Nicholas

Asam Valproic 1 Depakene Syrup 250 mg/5 ml Abbot

Na-Divalproic 1 Depakote ER Tablet 500 mg Abbot


2 Valeptik Tablet 250 mg Otto

Na-Phenitoin 1 Phenitoin Generik Capsul 100 mg


Injeksi 100 mg/2 ml
2 Dilantin Tablet 100mg Pfizer
3 Kutoin Injeksi 100 mg/2 ml Mersifarma

Carbamazepin 1 Carbamazepin Generik Tablet 200 mg


2 Tegretol Tablet 100 mg Novartis
Tablet CR 200 mg

Pregabalin 1 Lyrica Tablet 75mg Pfizer


2 Provelyn Tablet 75 mg Kalbe Farma

Gabapentin 1 Neurontin Capsul 300mg Pfizer


2 Ganin Tablet 300mg Ferron

H. OBAT SSP GOL. LAIN


Metilphenidate 1 Ritalin Tablet 10 mg Novartis

I. OBAT PENYAKIT NERODEGENARATIF


Donepezil HCl 1 Aricept Tablet 5 mg Eisai

J. OBAT ANTI PARKINSON


Triheksipenidil 1 THP Generik Tablet 2 mg
2 Heximer Tablet 2 mg Mersifarma

K. OBAT ANTIVERTIGO
Betahistine mesylat 1 Mertigo Tablet 8 mg Dexa Medica
2 Merislon Tablet 12 mg EISAI

9
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus

Cinnarizine 1 Stugeron Tablet 25 mg Jannson

L. ANALGESIC (OPIAT)
Tramadol 1 Tramadol Generik Capsul 50 mg
Injeksi 50 mg/ml
2 Tradyl tablet 50 mg Interbat
Injeksi 50 mg/ml
Tramadol + Parasetamol 1 Analtram Tablet Lapi

M. ANALGESIC (NON OPIAT)+ANTI PIRETIK


Paracetamol 1 Paracetamol Generik Tablet 500 mg
Syrup 120 mg/ 5 ml, 60 ml
Drop 100 mg/ml, 15 ml
2 Dumin Supp 125 mg, 250 mg Alpharma
3 Ottopan Drop 100 mg/ml Otto
4 Sanmol Tablet 500 mg Sanbe
Syrup 120 mg/5 ml, 60 ml
Drop
Infus 1000 mg
4 Farmadol Infus 1000 mg Fahrenheit
Tablet 500 mg
5 Pamol Syrup 120 mg/5 ml, 60 ml Interbat
Drop 125 mg, 250 mg
Supp
6 Pyrexin Syrup 120 mg/5 ml, 60 ml Meprofarm
7 Sumagesic Tablet 600 mg Medifarma

Ibuprofen 1 Ibufenz Syrup 100 mg/5ml, 60 ml Kalbe Farma


2 Anafen Syrup 100 mg/5ml, 60 ml Bernofarm
3 Bufect Forte Syrup 100 mg/5ml, 60 ml Sanbe
4 Bufect Syrup Sanbe
5 Proris Suspensi 200 mg/ 5 ml Pharos
Supp 125 mg

N. OBAT ANTI INFLAMASI NON STEROID


Ibuprofen 1 Ibuprofen Generik Tablet 400 mg Great

Ibuprofen Arginin 1 Spedifen Tablet 400 mg Zambon

Asam Mefenamat 1 Asam mefenamat Generik Tablet 500 mg Hexpharm


2 Mefinal Tablet 250 mg, 500 mg Sanbe
3 Mefinter Tablet 250 mg, 500 mg Interbat
4 Pondex Tablet 250 mg, 500 mg Dexa Medica

Ketorolac 1 Ketorolac Generik Injeksi 10 mg, 30 mg Hexapharm

Ketorolac Trometamin 1 Trolac Kaplet 10 mg Bernofarm


Injeksi 30 mg/ml
2 Torasic Tablet 10 mg Kalbe Farma
3 Ketopain Injeksi 30 mg/ml Soho
4 Ketrobat injeksi 30 mg, 10 mg interbat

Natrium diklofenac 1 Natrium diklofenac Generik Tablet 25mg, 50 mg Bernofar


2 Dolofenac Na Tablet Merck
3 Voltaren Tablet SR 75 mg Novartis
Tablet Retard 100 mg Novartis
Gel 1% 20 gr Novartis

Natrium diklofenac + Vit. B Plek 1 Neurofenac Plus Tablet 50 mg Merck

Kalium diklofenac 1 Cataflam D Tablet 50 mg Novartis


2 Cataflam Drop Drop Novartis
3 Cataflam Fast Sachet 50 mg Novartis
4 X-Flam Tablet 50 mg Combiphar
5 Diflam tablet 50 mg Interbat

10
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
Piroxicam 1 Piroxicam Generik Capsul 10 mg, 20 mg Esa Indo
2 Feldene Tablet 10 mg, 20 mg Pfizer
Gel

Meloxicam 1 Meloxicam Generik Tablet 7,5mg. 15mg Nulab


2 Artrilox Tablet 15 mg Combiphar
3 Mecox Tablet 15 mg Ferron
4 Meloxin Injeksi 10 mg /ml Interbat

Celecoxib 1 Celebrex Capsul 200mg Pfizer

Etoricoxib 1 Arcoxia Kaplet 60, 90, 120 mg MSD

Ketoprofen 1 Kaltrofen Suppos 100 mg Kalbe Farma


Injeksi 100 mg / 2ml
2 Pronalges Tablet 50 & 100 mg Dexa Medica
Supp 100 mg
Injeksi 100 mg / 2ml
3 Pronalges CR Tablet 200 mg Dexa Medica

Dexketoprofen 1 Ketesse Tablet Ferron


Injeksi
2 Fendex Injeksi 50 mg/2 ml Fahrenheit

Nabumetone 1 Goflex Tablet 500 mg Guardian

Metamizol Sodium Na 1 Norages Injeksi 500 mg/ml Meprofarm

Metampiron 1 Antalgin Generik/Lexagin Tablet 500 mg Molex Ayus

Metampiron +Chlordiazepoxid+Vit. B 1 Neurogen Tablet 500 mg Bernofarm


2 Neurodial Tablet Kimia Farma
3 Proneuron Tablet Meprofarm

Metampiron+Kafein+Vit.B 1 Neuralgin RX Tablet 500 mg Kalbe Farma

Tinoridine HCl 1 Nonflamin Capsul Takeda

Codein 30mg+Paracetamol 500mg 1 Coditam Tablet Kimia Farma

Paracetamol+Tramadol 1 Tramifen Tablet Otto


2 Ultracet Tablet Janssen
3 Analtram tablet
O. ANTI MIGRAIN
Flunarizine 1 Degrium Tablet 5 mg Dexa Medica
2 Frego Tablet 5 mg, 10 mg Kalbe Farma

P. NOOTROPIK DAN NEUROTONIK


Piracetam 1 Piracetam Generik Capsul 800 mg Novell
Injeksi 1 gr, 3 gr
Infus 12 gr/60 ml
2 Latropil Syrup 500 gr/5ml Lapi
3 Neurotam Capsul 800 mg Kalbe Farma
Injeksi 1 gr/5 ml
4 Fepiram Injeksi 3gr/15ml Ferron
Infus 12gr/60 m
5 Benocetam Injeksi 3 gr/15 ml Bernofarm

Pyritinol HCl Monohydrate 1 Encephabol Tablet 100 mg Merck


Syrup 100 ml

Sulbutiamine 1 Arcalion Tablet 200 mg Servier

Mecobalamin 1 Mecobalamin Generik Injeksi 500 mcg Nulab

2 Labipal Capsul 500 mcg Lapi


Injeksi 500 mcg
3 Megabal Capsul 500 mcg sanbe

11
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
4 Methycobalt Capsul 250 mcg Eisai
Injeksi 500 mcg

V. SISTEM MUSKULOSKELETAL

A. DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARD)


-
B. OBAT HIPERURISEMIA & GOUT
Allopurinol 1 Allopurinol Generik Tablet 100 mg, 300 mg Hexapharm
2 Zyloric Tablet 100mg Glaxo
3 Benoxuric Tablet 300mg Bernofarm
5 Urica Tablet 100mg, 300mg Sandoz

Colchicine 1 Recolfar Tablet 0.5 mg Fahreinheit

C. RELAKSAN OTOT
Eperisone HCl 1 Myonal Tablet 50 mg Eisai
2 Myori Tablet Tempo

Tizanidine HCl 1 Myores Tablet 2 mg Meprofarm

D. ENZIM ANTIIMFLAMASI
Serrotiopeptidase 1 Flavin Tablet Landson

Serapeptase 2 Dansera Tablet Otto

E. OBAT LAIN YANG BEKERJA PADA SISTEM MUSKULOSKELETAL


Glucosamine HCl+Condroitine 1 GCM Kaplet Simex
2 GCM Forte Kaplet Simex

Glucosamine HCl+Condroitine+OM3 1 Zotic Kaplet 30 mg Novell

Glucosamine Sulfat 1 Mediflex Krim Kalbe Farma

VI. HORMON

A. ANDROGEN & PREPARAT SINTETIKNYA


Testosteron Undekanoat 1 Andriol Kapsul 40 mg Schering

Danazol 1 Azol Tablet 200 mg Merck

B. ESTEROGEN & PROGESTERON SERTA PREPARAT SINTETIKNYA


Estradiol valerate+Nogestrel 1 Cyclo-Progynova Tablet Bayer

Estrogen Konjugasi 1 Estero Tablet 0.625 mg

Norethisteron 1 Norelut Tablet 5mg Dexa Medica


2 Regumen Tablet 5mg Sanbe

Medroxyprogesterone acetat 1 Provera Tablet 10mg Pfizer

Nomegestrol Acetat 1 Luthenyl Kaplet Merck

Ethinylestradiol 1 Lynoral Tablet Organon

C. KOMBINASI HORMON-HORMON KELAMIN


-
D. HORMON KORTIKOSTEROID
Sama dengan Anti Alergi

E. HORMON-HORMON TROPIK & PREPARAT SINTETIKNYA


Leuprolide Acetate 1 Endroline Injeksi 3.75 mg Kalbe Farma

12
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus

Clomiphene Citrat 1 Blesifen Tablet 50mg Sanbe


2 Ofertil Tablet 50mg Bernofarm
3 Profertil Tablet 50mg Darya Varia
4 Provula Tablet 50mg Dexa Medica

F. PREPARAT ANABOLIK
-
G. OBAT LAIN YANG MEMPENGARUHI REGULASI HORMONAL
-

VII. KONTRASEPSI

A. KONTRASEPSI ORAL
Desogestrel 1 Cerazette Tablet 75 mcg Schering

Cyproterone acetate+Ethinylestradiol 1 Diane Tablet Schering

Lynestrenol 1 Exluton Limas Tablet 0,5 mg Schering

Levonorgestrel 1 Microlut Tablet 30 mcg Bayer

Levonorgestrel+Ethinylestradiol 1 Mycroginon Tablet Bayer


2 Triquilar ED Tablet Schering

Ethynilistradiol+Drospirenone 1 Yasmin Tablet Bayer


2 Yaz Tablet Bayer

Estradiol+Drospirenone 1 Angeliq Tablet Bayer

1 Engelic Tablet Schering

B. KONTRASEPSI SUNTIK
1 Cyclofem Injeksi Schering

C. KONTRASEPSI LAIN
1 Andalan Tablet Bayer

VIII. ANTI INFEKSI (SISTEMIK)


A. AMINOGLIKOSIDA
Gentamycin 1 Gentamycin Generik Injeksi
2 Sagestam Injeksi Sanbe
3 Gentalex cream Cream Molex Ayus

Kanamycin Sulfat 1 Kanamycin Meiji Injeksi 1 gr, 2gr Meiji

Amikasin Sulfat 1 Amikasin Sulfat Generik Injeksi 250 mg/2 ml Dexa medica
2 Mikasin Injeksi 500mg/2ml Kalbe Farma
3 Simikan Injeksi 250 mg/2 ml Bernofarm
4 Glybotic Injeksi 250 mg, 500 mg Sanbe

Phospomycin 1 Phosmycin Injeksi 500 mg Meiji

Streptomycin Sulphat 1 Streptomycin Sulphat Injeksi 1 gr Meiji

B. SEFALOSPORIN
GENERASI I
Sefadroxil 1 Cefadroxil Generik Capsul 500mg Bernofarm
Syrup
2 Cefat Syrup 125 mg/ 5 ml Sanbe
Capsul 500 mg
3 Cefat F Syrup 250 mg/ 5 ml Sanbe
4 Dexacef F Syrup Dexa Medica
Capsul

13
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
5 Renasistin Drop Fahrenheit

Sefalexin 1 Cefalexin Generik Capsul 500 mg


2 Cefabiotic Syrup 125 mg/5 ml Bernofarm
Capsul 500 mg

Sefazolin 1 Evalin Injeksi 1 gr Soho

GENERASI II
Sefaklor 1 Cefachlor Generik Capsul 500 mg
2 Sochlor Syrup 500 mg Soho

Sefuroksim 1 Cefuroxim Generik Capsul


2 Cethixim Capsul 500mg Ethica
3 Cituroxim Kaplet 500 mg Puspa
Injeksi 1000 mg
4 Celocid Injeksi 750 mg Dexa Medica

GENERASI III
Sefiksim 1 Cefixim Generik Syrup 100mg, 200mg Hexpharm
Tablet 200 mg
2 Cefila Drop 150 mg /5 ml Lapi
3 Cefspan Capsul 200mg Kalbe Farma
Syrup 100 mg/ 5 ml
4 Ceptik Capsul 100mg Interbat
Syrup 100 mg/ 5ml
5 Comsporin Capsul 200 mg Combiphar
6 Sporetik Syrup 100 mg/ 5 ml Sanbe
7 Tocef Syrup 100 mg/ 5 ml Bernofarm
8 Ximesco Capsul 200mg Escolab

Sefoperazon 1 Sefoperazon Generik Injeksi 1 gr Novell


2 Yazon Injeksi 1 gr Yarindo

Seftriakson 1 Ceftriaxon Generik Injeksi 1 gr Dexa


2 Starxon Injeksi 1 gr Interbat
3 Cefxon Injeksi Lapi
4 Gracef Injeksi 1 gr Gracia
5 Tyason Injeksi 1 gr Combiphar
6 Broadced Injeksi 1 gr Kalbe Farma
7 Cefaxon Injeksi 1 gr Kimia Farma
8 Terfacef Injeksi 1 gr Sanbe

Sefotaksim 1 Cefotaxim Generik Injeksi 1gr


2 Taxegram Injeksi 1gr Sanbe
3 Combicef Injeksi 1gr Combiphar
4 Claforan Injeksi 1 gr Aventis
5 Rycef Injeksi 1 gr Interbat

Seftazidim 1 Ceftazidime Generik Injeksi 1gr


2 Zidifect Injeksi 1gr Sanbe
3 Lacedim Injeksi 1gr Lapi
4 Fortum Injeksi 1gr Glaxo
5 Ceftum Injeksi 0,5 gr, 1 gr Ferron

Seftizoksim 1 Ceftizoxime Na Generik Injeksi Novell


2 Cefizox Injeksi 1 gr Kalbe Farma
3 Tizos Injeksi 1 gr Dexa Medica

Sefotiam 1 Ceradolan Tablet Takeda

GENERASI IV
Sefditoren pivoksil 1 Meiact Tablet 200 mg Meiji

Sefpirom 1 Sefpirom Generik Injeksi 1 gr Hexapharm

Sefepim 1 Cefepime Generik Injeksi


2 Macef Injeksi Bernofarm

14
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
3 Rapime Injeksi Fahrenheit

C. PENISILIN
Procain Penicillin G 1 Procain Penicillin G Injeksi 3.000.000 IU Meiji

Ampicillin 1 Ampicillin Generik Syrup


Injeksi

Amoxycillin 1 Amoxycillin Generik Tablet 500mg, 250mg Berno


Syrup Holi
2 Amoxsan Tablet Sanbe
Syrup
Drop
Injeksi
3 Intermoxil Tablet 500mg,1000mg Interbat

Amoxycillin + Clavulanic acid 1 Co - Amoyclav Generik Tablet Dexa Medica


2 Claneksi Tablet, Syrup Sanbe
3 Comsikla Capsul Combiphar
4 Claneksi F Syrup Sanbe
5 Clabat Syrup, Tablet 500mg tab Interbat
6 Dexyclav Tablet Dexa Medica

Sulbenicillin disodium 1 Kedacillin Injeksi 1 gr Takeda

Ampicillin + Sulbactam 1 Bactesyn Tablet 375mg Kalbe Farma


Injeksi 750mg, 1500mg Kalbe Farma
2 Pycin Injeksi 1500mg Bernofarm
3 Cinam Injeksi 1500mg Sanbe

D. PENICILIN + BETA LAKTAM


Meropenem 1 Meropenem Generik Injeksi 0,5 gr, 1 gr Novell
2 Merofen Injeksi 1 gr Kalbe Farma
3 Merotik Injeksi 0,5 gr Lapi
4 Merosan Injeksi 0,5 gr, 1 gr Sanbe

Imipenem + cilastatin 1 Timipen Injeksi 1gr Interbat


2 Pelastin Injeksi 1gr Sanbe

E. KLORAMPENIKOL
Thiamfenikol 1 Thiamfenicol Generik Capsul 500mg
2 Biothicol Capsul Sanbe
3 Lacophen Suspensi Lapi
4 Thiamycin Capsul Interbat
Syrup

Klorampenikol 1 Chlorampenicol Generik Capsul


Syrup
2 Colsancetine Injeksi 1gr Sanbe
3 Chloramex Injeksi 500mg Actavis

F. MAKROLID
Erytromicin 1 Erytromicin Generik Capsul
Syrup
2 Erythrin Syrup Interbat
3 Erysanbe Capsul 250mg, 500mg Sanbe
Syrup

Claritromycin 1 Claritromycin Generik Tablet 250 mg


2 Bicrolid Tablet 250mg Sanbe

3 Abbotic XL Caplet 500mg Glaxo


4 Abbotic Syrup Glaxo
5 Comtro Syrup Combiphar

Azithromycin 1 Azithromycin Generik Tablet


2 Mezatrim Tablet 200mg Sanbe
3 Zifin Tablet Fahrenheit

15
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
4 Zistic Capsul 500mg Bernofarm
Syrup
5 Zithromax Tablet Pfizer
Syrup
6 Azomax Tablet Dexa Medica
Syrup
7 Zycin Tablet 500 mg Interbat

Spiramycin 1 Spiramycin Generik Tablet


2 Profamed Tablet 500mg Promed
3 Spiranter Tablet 500mg Interbat
4 Spirasin Tablet 500mg Sanbe

G. KUINOLON
Ciprofloxacin 1 Ciprofloxacin Generik Tablet 500 mg Berno
2 Baquinor F Tablet Sanbe
Infus
3 Interflox Tablet 500mg Interbat

Ofloxacin 1 Ofloxacin Generik Tablet 400mg


2 Prolecin Tablet 400mg Promed
3 Ethiflox Tablet 200 mg Ethicha

Levofloxacin 1 Levofloxacin Generik Tablet 500 mg Dexa


Infus 500 mg
2 Cravit Tablet 500 mg Kalbe Farma
Infus 500 mg
3 Lexa Tablet 500 mg Landson
Infus 500 mg
4 Cravox Tablet 500 mg Lapi
Infus 500 mg
5 Floxacom Tablet 500 mg Combiphar
6 Farlev Infus 750 mg Fahreinheit

H. TETRASIKLIN
Tetracycline 1 Tetracycline Generik Capsul 250mg, 500mg
2 Tetrin Capsul 500 mg Interbat

Doxyciclin 1 Doxyciclin Generik Capsul 100mg


2 Siclidon Capsul 100mg Sanbe

I. ANTI BAKTERIAL KOMBINASI


Sulfametoxazole +Trimetoprim 1 Cotrimoxazole Generik Syrup 200/40 mg
Tablet 400/80 mg
2 Sanprima Syrup 200/40 mg Sanbe
Tablet 400/80 mg
3 Sanprima F Tablet 800/160 mg Sanbe

J. ANTI BIOTIK GOL. LAIN


Clindamycin 1 Clindamycin OGB Capsul 150mg, 300mg Dexa Medica
2 Biodasin Capsul 300mg Promed
3 Climadan Capsul 300 mg Kalbe Farma
4 Prolic Capsul 150mg, 300mg Sanbe
5 Clinmas Capsul 300mg Lapi

Lincomycin 1 Lincomycin Generik Capsul


2 Biolincom Capsul 500 mg Otto
Syrup 250 mg /5 ml
3 Nolipo Capsul 500mg Sanbe

Vancomicin 1 Vancep Injeksi 500mg Fahrenheit

Polimiksin E sulfat 1 Colistine Tablet 1.500.000 IU Actavis

L. OBAT ANTI JAMUR


Griseofulvin 1 Griseofulvin Generik Tablet 500mg

Ketokonazole 1 Ketokonazole Generik Tablet 200 mg

16
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
2 Interzol Cream Interbat

Fluconazole 1 Fluconazole Generik Capsul 100 mg


Infus 100 mg Novell
2 Cryptal Infus 200 mg Fahrenheit
Tablet 50 mg
3 Diflucan Capsul 50 mg Pfizer
4 Flucoral Capsul 50 mg Kalbe Farma
5 Govazole Capsul 150 mg Guardian

Itraconazole 1 Sporacid Capsul 100 mg Ferron


2 Itzol Tablet 100 mg Lapi

Nystatin 1 Fungatin Drop Ferron


2 Nymico Drop Sanbe
3 Kandistatin Drop Metiska
M. ANTI VIRUS
Acyclovir 1 Acyclovir Generik Tablet 200 mg, 400 mg Kimia Farma
2 Virtaz Tablet 400 mg Fahrenheit
3 Clinovir Tablet 200 mg Pharos

Isoprinosin 1 Isoprinosin Tablet Darya Varia


Syrup
2 Isprinol Tablet Novell
Syrup

Valacyclovir 1 Valtrex Tablet 500 mg Glaxo


2 Valvir Tablet 500 mg Soho

Telbivudine 1 Sebivo Tablet 600 mg Novartis

Lamivudine 1 3TC-HBV Tablet 100 mg Glaxo


2 Hiviral Tablet 150 mg Kimia Farma

Zidovudine 1 Retrovir Capsul 100 mg Glaxo

Zidovudine + Lamivudine 1 Duviral Tablet 300 mg/ 150 mg Kimia Farma

Nevirapine 1 Neviral Tablet 200 mg Kimia Farma

Efavirenz 1 Efavirenz Tablet 600 mg Matrix - India


2 Estiva-600 Tablet 600 mg Hetero - India

Stavudine 1 Staviral Tablet 30 mg Kimia Farma

Tenofovir 1 Viread Tablet 300 mg Gillead


2 Tenofovir Generik Tablet 300 mg Mylan - India
3 Tenofovir Generik Tablet 300 mg Matrix - India

Tenofovir + Emtricitabine 1 Truvada Tablet 300/200 mg Gilead

Didanosine 1 Videx Tablet 125 mg Bristol-Myers Sq

Lopinavir + Ritonavir 1 Aluvia Tablet 200 mg/ 50 mg Abbott

Zidovudin + Lamivudine + Nevirapine 1 FDC Tablet Dispersi 60/30/50

Stavudine + Lamivudine + Nevirapine 1 Triomun Junior Tablet Dispersi 12/60/100mg

N. ANTI CACING
Pyrantel 1 Pyrantel Generik Tablet 125 mg
2 Combantrin Tablet 125 mg, 250 mg
Syrup 360 mg/5 ml
3 Vermic Syrup 360 mg/5 ml Indofarma

Mebendazol 1 Vermox 500 Tablet 500 mg Janssen

O. ANTI MALARIA

17
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
Chloroquin 1 Chloroquin Generik Tablet 250 mg Kimia Farma
2 Malarex Tablet 250 mg Actavis

Kina 1 Kina Generik Tablet 500 mg Kimia Farma

Artemether 1 Artem Injeksi 80 mg/ ml Multimitra


2 Artesunate Generik Injeksi

Primetamin 1 Primet Tablet 25 mg Kimia Farma

Sulfadoxin + Pirimetamin 1 Fansidar Tablet 500 mg/25 mg Roche

P. ANTI AMUBA
Metronidazole 1 Metronidazole Generik Tablet 500 mg
Infus 1 gr
2 Fladex Infus 1 gr Dexa Medica
3 Flagyl Forte Supp 1 gr Aventis
Syrup 125 mg/5 ml
4 Promuba Syrup 125 mg/5 ml Meprofarm
5 Trichodazole Infus 1 gr Sanbe

X. SISTEM KEMIH KELAMIN

A. PREPARAT VAGINA
Metronidazole + Nistatin 1 Trichodazole Plus Ovula Vag. Tablet Sanbe
2 Vagistin Ovula Vag. Tablet Combiphar
3 Neo Gynoxa Vag. Tablet Kalbe Farma

Progesteron 1 Cygest Pesary Vag. Tablet Alpharma

Policresulen 1 Albothyl Ovula Vag. Tablet Pharos

2 Lactasid Vag Gel

B. ANTISEPTIK SALURAN KEMIH


Asam Pipemidat 1 Urinter Capsul 400mg Interbat
2 Urispas Capsul 200mg Indofarma
3 Urotraktin Capsul 400mg Sanbe

Ekstrak Daun Tempuyung 1 Nephrolit Capsul Kalbe Farma


2 Batugin Eliksir Kimia Farma

Sericocalyx folium+Orthosiphon herba 1 Renax Tablet Interbat

C. OBAT YANG BEKERJA PADA UTERUS


Methylergometrine 1 Metilat Tablet Metiska Farma

Synthetic Oxytocin 1 Induxin Injeksi Kalbe Farma


2 Piton-S Injeksi Organon

Isoxsuprine HCl 1 Duvadilan Injeksi Kimia Farma


2 Hystolan Tablet Dexa Medica

Allylestrenol 1 Pregnolin Tablet 5mg Dexa Medica


2 Prestrenol Tablet Interbat
3 Preabor Tablet 5mg Sanbe
4 Premaston Tablet 5mg Kalbe Farma

D. OBAT UNTUK DISFUNGSI EREKSI


Sildenafil 1 Viajoy Capsul 50 mg Otto

Vardenafil 1 Levitra Tablet 5 mg, 10 mg Bayer

E. OBAT UNTUK PENYAKIT SALURAN KEMIH & PROSTAT


Ekstrak Pumpkin seed ELFA 940 1 Inkurin Tablet 250 mg Interbat

18
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
Tamsulosin HCl 1 Harnal D Tablet Glaxo

Solifenacin Suksinat 1 Vesicare Tablet 5 mg Astellas

F. OBAT SALURAN KEMIH KELAMIN GOL. LAIN


Ketoacid 1 Aminefron Caplet Dexa Medica
2 Tonar Kaplet Sandoz
3 Renoguard Capsul Ikapharmindo
4 Nocid Capsul Kalbe Farma
5 Prorenal Capsul Novell

Tribulus terrestris 1 Tribestan Tablet 250mg Metiska Farma

Tribulus+Muira puama+Damiana+Ginseng 1 Unigen Capsul Nutrindo

Tribulus+cordioseps+Butea sup+Ginseng 1 Erefit Soft Capsul Escolab

XI. SISTEM ENDOKRIN DAN METABOLIK

A. PREPRAT INSULIN
Human Insulin Reguler Intermediate Acting 1 Actrapid HM 100 Vial 100 iu/ml 10 ml Novonordisk
2 Sansulin N Cartridge 100 iu/ml 3 ml Sanbe

Insulin Analog Rapid Acting 1 Novorapid Penfill Injeksi Novonordisk


2 Humalog R Eli Lily

Insulin Analog Premix 30/70 1 Novomix Penfill Penfill Novonordisk

Insulin Analog 25/75 1 Humalog Mix 25 Cartridge Eli Lily

Insulin Analog Long Acting/Basal 1 Levemir Penfill Penfill Novonordisk

B. ORAL ANTI DIABETES


Glibenclamid 1 Glibenclamid Generik Tablet Kimia Farma

Gliclazide 1 Diamicron MR Tablet 30mg, 60 mg Servier

Metformin HCl 1 Metformin HCl Generik Tablet 500 mg, 750 mg Hexpharm
2 Glucophage Tablet 500 mg Merck
3 Glumin XR Tablet 500 mg, 750 mg Ferron
4 Forbetes Tablet 500 mg Sanbe

Glibenclamid + Metformin HCl 1 Glucovance Tablet 1.25/250,2.5/500 Merck


5/500
Gliquidone 1 Gliquidone Generik Tablet Dexa Medica
2 Glurenorm Tablet 30mg Boehringer

Glimepiride 1 Glimepiride Generik Tablet 1mg, 2 mg Nulab


2 Amadiab Tablet 1mg
3 Amaryl Tablet 2mg Aventis
4 Glucoryl Tablet 2mg Bernofarm
5 Metrix Tablet 3mg Kalbe Farma

Pioglytazone 1 Actos Tablet 30mg Takeda

Vildagliptin + Metformin HCl 1 Galvusmet Tablet 50/500, 100/500 Dexa Medica

Sitagliptine 1 Januvia Tablet 50 mg, 100 mg MSD

Sitagliptine + Metformin 1 Janumet Tablet 50mg / 500mg MSD

Saxagliptin + Metformin 1 Kombiglyze XR Tablet 5/500 AstraZeneca

Acarbose 1 Glubose Tablet 50 mg Ferron

C. HORMON TIROID

19
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
L-Thyroxine Na 1 Thyrax Tablet 50 mcg Granon
2 Euthyrax Tablet 50 mcg Merck

D. ANTI TIROID
Prophyltiouracyl 1 PTU Generik Tablet 50 mg, 100mg

Carbimazole 1 Neo Mercazol Tablet 5mg Nicholas

Tiamizole 1 Thyrozol Tablet 5mg, 10mg Merck


E. OBAT ANTIOBESITAS
Orlistat 1 Xenical Capsul 120 mg Roche

F. OBAT METABOLISME TULANG


Calcitriol 1 Ostriol Capsul Lunak 0,25 mcg Fahrenheit
2 Kolkatriol Capsul Phapros

XII. VITAMIN DAN MINERAL

A. VITAMIN A, D & E
Vitamin A 1 Vitamin A Tablet 20000IU,50000IU Kimia Farma

Tocopherol 1 Dalfarol Capsul 100IU, 400IU Nutrindo


2 Lanturol Capsul Landson

B. VITAMIN B
B1 1 Vitamin B1 Generik Tablet 50mg
B6 2 Vitamin B6 Generik Tablet 10 mg
B12 3 Vitamin B12 Generik Tablet

Vitamin B Komplek 1 Vitamin B comp Generik Tablet


2 Neurobat Forte Injeksi Interbat
3 Neurobion Tablet 1000 mg, 5000 mg Merck
Injeksi 5000 mg
4 Neuromed Tablet 5000 mg Promed
5 Neurosanbe Tablet 1000 mg, 5000 Merck
6 Becombion Syrup 110 ml Merck
7 Mersibion Injeksi 5000 mg Mersifarma

C. VITAMIN C
Ascorbid Acid 1 Vitamin C Generik Tablet 50 mg Kimia Farma
2 Extrace Injeksi 500mg Ethica

D. ASAM FOLAT 1 Folavit Tablet Sanbe


2 Fetavita Tablet Escolab
3 Folamil genio Capsul
4 Nerva plus Tablet Gracia
5 Osfit DHA Tablet Kalbe Farma
6 Folaplus Tablet Meprofarm
7 Vitamam Tablet 1, 2, 3 Novell
8 Vomilat Tablet Kalbe Farma

E. MULTI VITAMIN
Vitamin E + B Komplek 1 Neurovit E Tablet Kimia Farma
2 Sanbe Plex Drop Sanbe

Fursultiamin+Vit B12 1 Alinamin F Tablet Takeda


Injeksi
F. KALSIUM
1 Calnic Syrup
2 Calsium Gluconas Generik Injeksi
3 Calsium Laktat Generik Tablet
4 CDR Tablet eff Bayer
Tablet
5 Ossovit Tablet Interbat
6 Calos Tablet 500 mg Fahrenheit

20
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
G. MULTIVITAMIN DAN MINERAL
Bonistein+Ca+VitK+Vit D3 1 Hi-Bone Tablet Otto

Calsium dan Multi Vitamin 1 Elkana Syrup Sanbe

Multivitamin + Mineral 1 Apyalis Drop Lapi


Syrup
2 Visebad Drop Otto

3 Cernevit Injeksi Kalbe Farma

4 OreZinc Sachet Novell


5 Zink Care Tablet eff Kalbe Farma
6 Zinc Pro Syrup Combiphar

7 Natursif Syrup Bernofarm


8 Vitaplex Syrup Bernofarm
Drop
9 Provital Plus Capsul Landson
10 Becom C Tablet Sanbe
11 Becom Zet Tablet Sanbe
12 Farmabex-C Tablet Fahrenheit
13 Zegavit Tablet Kalbe Farma
14 Zamel Syrup Novell
15 Sim DHA Syrup Simex
16 Inlacta DHA Capsul Interbat
17 Prolacta DHA Capsul Novell
18 Likurmin Syrup Kalbe Farma

Multivitamin Mata
Billberry + Retinol + Vit. E 1 Berry vision Tablet Sanbe
tablet disp
2 Eye bright Tablet
3 Eyevit Syrup

4 Vitanorm Tablet

B-Carotene+Vit. E+Zn+Se+Lutein Ester 1 Retivit Tablet

H. ZAT BESI
Sulfas Ferosus 1 Sulfas Ferosus Generik Tablet Phapros
2 Biosanbe Tablet Sanbe
3 Dasabion Capsul Kimia Farma
4 Hemobion Tablet Merck
5 Inbion Capsul Interbat
6 Maltiron Capsul Meprofarm
7 Maltofer Syrup Combiphar
8 Natavit Capsul Bernofarm
9 Nonemi Tablet Lapi
10 Emineton Tablet Kalbe Farma

Iron Sucrose 1 Venofer Injeksi 100 mg Combiphar

XIII. NUTRISI

A. NUTRISI ENTERAL
1 Peptisol Box/Pack Kalbe Farma
2 Diabetasol Box/Pack Kalbe Farma
3 Nephrisol Box/Pack Kalbe Farma
4 Nitrisol Box/Pack Fahrenheit
5 Vip Albumin Capsul Royal Medicine
6 Sirplus Syrup Meprofarm

B. ELEKTROLIT DAN MINERAL


Kalium 1 Aspar K Tablet 300 mg Tanabe
2 KSR Tablet 600 mg Merck
3 Renalyte Cairan 200 mg Fahrenheit

21
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
4 Renapar Tablet 10 mg Fahrenheit

Oralit 1 Oralit Sachet Kimia Farma


2 Trolit Sachet Kalbe Farma
3 Renalyte Cairan 500 ml Fahrenheit
4 Pharolit Sachet Phapros

C. PERANGSANG NAFSU MAKAN


Curcuminoid 1 Apecur Syrup 100 ml Simex
2 Curvit Kaplet Soho
3 Curvit CL Emulsion Syrup 175 ml Soho

Curcuma+Papain Zingiber 1 Digezym Tablet Ethica

D. SUPLEMENT DAN TERAPI PENUNJANG


1 Anti Oksidan
1 Seloxy Kaplet Ferron
2 Lycoxy Tablet Dexa Medica
Gliadin+SOD 3 Glisodin Capsul Kalbe Farma
Astaxantin Natural 4 Asthin Bond Capsul Soho
5 Oxypen Tablet Ferron

Lechitine+B plek+Vit. E+Karoten 1 Escovit Tablet Escolab

2 Imunomodulator
Malicacid+Arginin+Glysirizin+Glukosamine 1 Aviter Sachet Interbat

Echinasea+Zn 1 Imboost Force Capsul Soho


Syrup

Echinasea+Kalsium Ascorbate 1 Imunvit plus Tablet Simex

Echinasea+Se+Vit. C 1 Imesco Tablet Escolab

Echinasea+ 1 Imunos Tablet Lapi


Syrup
Phyllantus Niruri L 1 Divens Syrup 25 mg/5ml Dexa Medica

Arabynoxilan derivatives 1 Biobran Tablet 250 mg Ferron

Ekstrak Plasenta+B12+Ca. Phosfate 1 Laktafit Tablet Dexa Medica

Trigonella Foenum-graecum+Sauropus andr 1 Lactamam Tablet Novell


2 Lactafar Tablet Fahrenheit

L-Glutamin 1 Glutrop Tablet 1000 mg Tropica Mas

XIV. MATA

A. ANTIINFEKSI & ANTISEPTIK MATA


Levofloxacin 1 Cravit Tetes Mata Ferron
2 LFX Mini Dose 0,6 ml Cendo

Ofloxacin 1 Tarivid Tetes Mata Kalbe Farma

Moxyfloxacin 1 Vigamox Tetes Mata 0,5% Alcon

Oxytetra 1 Oxytetracyclin Generik Eye Oint 1% 3.5 gr

Chloramfenicol 1 Chloramfenicol Generik Eye Oint


Tetes Mata
2 Cendo Fenicol Salep Mata
3 Kemicetine Salep Mata 1% 5 gr Kalbe Farma
Tetes Mata 0,5% 5 ml

Gentamycin 1 Gentamycin Generik Salep Mata

22
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
2 Cendo Genta Salep Mata
Tetes Mata

Dibekacin Sulfate 1 Dibekacin Tetes Mata Meiji

Polymicin sulfate + Gramicidine 1 Cendo polygran Salep Mata Cendo


Tetes Mata

Acyclovir 1 Cendo Hervis Salep Mata Cendo

Asam Fusidat 1 Cendo Pipthalmic Salep Mata Cendo

Natamicin 1 Natacen Tetes Mata

B. ANTISEPTIK MATA DENGAN KORTIKOSTEROID


Tobramycin + Dexametason 1 Cendo Tobroson Salep Mata Cendo
2 Cendo Tobroson MD TM Mini Dose
Dexametason + Neo + Polymicin 1 Cendo Xytrol Salep Mata Cendo
Tetes Mata 5 ml
Polinicin+Neo+Gramycidin 1 Cendo Polydex Mini Dose Cendo

C. KORTIKOSTEROID MATA
-

D. OBAT MIDRIATIKUM
Tropicamide 1 Cendo Midriatil Tetes Mata 1% 5ml Cendo

E. OBAT MIOTIKUM
Sulfas Atropin 1 Cendo Tropin Tetes Mata 0,5 % Cendo

F. PREPARAT ANTIGLAUKOMA
Timolol Maleate 1 Cendo Timol Tetes Mata Cendo

Betaxolol 1 Tonor Tetes Mata 5.00% Cendo

Acetazolamide 1 Glaucon Tablet

G. OBAT DEKONGESTAN, ANESTESI, ANTIINFLAMASI MATA


Pemirolast Protasium 1 Allegysal Tetes Mata 2% 5 ml Ferron

Diclofenac Na 1 Flamar Tetes Mata SANBE

Vit. A+Zinex+Phenylephrine 1 Cendo Augentonic MD Tetes Mata Cendo

Neomycine + Polymicine +Phenylephrine 1 Cendo Statrol Tetes Mata Cendo

Tetracaine 1 Cendo Pantocain Tetes Mata 0.5% 5ml, 2% 5 ml Cendo

Polyvinylpyrolidone 1 Protagenta MD Mini Dose Cendo

H. PELUMAS MATA
N-acetylcarnocine 1 Clarastill Tetes Mata Kalbe Farma

glycerol+tyloxapol 1 Cationorm Tetes Mata Kalbe Farma

Dextran + hypromellose 1 Sanbe Tears Tetes Mata Sanbe

Hydropropyl methylcelluloce+Retinol P 1 Lubricent Salep Mata

Vit. A+Aneurin hydrocloride+Ca. Panto T 1 Rephitel Salep Mata

I. PREPARAT MATA GOL. LAIN


Cromolyn Sodium 1 Conver MD Mini Dose Cendo

K-iodida + Na-Iodida 1 Vitrolenta Tetes Mata 5 mg Cendo


2 Cendo Catarlent

23
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
Sodium Hyaluronate 1 Hyalub Mini Dose 5 mg Cendo

Pironoxine 1 Lentikular Tetes Mata Cendo

Carboxymethil Cellulose Sodium 1 Cenfresh Tetes Mata Cendo

XV. TELINGA DAN MULUT/TENGGOROKAN

A. ANTIINFEKSI & ANTISEPTIK


Ofloxacin 1 Akilen Tetes Telinga Sanbe
2 Tarivid Otic Tetes Telinga Kalbe Farma

B. ANTISEPTIK DAN KORTIKOSTEROID


Polymixine+Neomycine+Fludrocortison+lidoca 1 Otopain Tetes Telinga Interbat
2 Otilon Tetes Telinga Sanbe

Polymixine+Neomycine+Betametason+lidocai 1 Otozambon Tetes Telinga Zambon

C. PREPARAT TELINGA GOL. LAIN


Docusate Na 1 Forumen Tetes Telinga Sanbe

D. PREPARAT MULUT/TENGGOROKAN
Triamcinolone Acetonide 1 Ketricin Tablet Ferron
Gel
2 Kenalog Cream Taisho
3 Solcoseryl Gel 5 gr Pharos

Benzydamine HCl 1 Tantum verde Kumur 120 ml Soho

Hyaluronic Acid 1 Sanorin Kumur

2 Albothyl Solution Pharos

3 Betadine Kumur 190 ml Kimia farma

XVI. KULIT

A. ANTIBIOTIK TOPIKAL
Neomycin + Ekstrak Plasenta 1 Bioplacenton Gel Kalbe Farma

Ekstrak Plasenta + B12 1 Lactasid Dewasa Solution Sanofi


2 Lactasid Bayi

Silver Sulfadiazine 1 Burnazin Cream Darya Varia

Chloramfenicol 1 Chloramfenicol Generik Salep


2 Kalmicetin Cream Kalbe Farma

Gentamycin 1 Garamycin Cream 0,1% Schering


2 Gentamycin Generik Cream 0,1%

Neomycin Bacitracin 1 Nebacetin Salep Pharos


powder

Oxytetra 1 Oxytetracyxlin Generik Salep

Mupirocin 1 Bactroban Salep 2% 10gr Glaxo


2 Pibaksin Salep 2% 10gr Sanbe

Fusidic Acid 1 Fusycom Cream Combiphar

B. KORTIKOSTEROID TOPIKAL
Momethasone 1 Elocon Cream Schering
2 Motaderm Cream Bernofarm

24
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
Betamethasone 1 Betamethasone Generik Cream

Fluosinolon 1 Cinolon Cream Sanbe

Hydrocortison 1 Hydrocortison Generik Cream

Desoximethasone 1 Esperson Cream Aventis


2 Inerson Cream Interbat

Desonide 1 Apolar Cream Alpharma

C. ANTIJAMUR & ANTIPARASIT TOPIKAL


Miconazole Nitrat 1 Miconazole Generik Cream

Ketoconazole 1 Ketoconazole Generik


2 Mycoral Cream Kalbe Farma
3 Interzol Cream Interbat

Nystatin+Zinc Oxide 1 Myco Z Cream

Lindane+Usnic Acid 1 Scabicid Cream Kimia Farma

Sulfur 1 Salep 2-4 Salep Kimia Farma

D. ANTIVIRUS TOPIKAL
Acyclovir 1 Acyclovir Generik Cream
2 Zoter Cream Interbat
3 Virtaz Cream Fahrenheit

E. ANTIINFEKSI TOPIKAL DENGAN KORTIKOSTEROID


Desonide+Neomycine Sulphate 1 Apolar N Cream Alpharma
2 Desolex - N Cream

Fluosinolon+Neomycine Sulphate 1 Cinolon - N Cream Sanbe

Clotrimazol+Betamethason 1 Lotriderm Cream Schering

F. PREPARAT AKNE
Clindamycin + Tretinoid 1 Mediklin TR Cream 15 gr Suryaderm

Clindamycin+Zn Acetate 1 Climadan Acne Cream 15 gr Kalbe Farma

G. ANTIHISTAMIN/ANTIPRURITUS TOPIKAL
1 Caladin Lotion
2 Caladril Powder

H. PREPARAT PSORIASIS, SEBOROIK, & IKTIOSIS

I. KERATOLITIK
Ektrak Camomile 1 Kamillosan Cream Asta Medica

Asam Salisilat 1 Asam salisilat Solution 3%

J. EMOLIEN & PELINDUNG KULIT


Etilhexil-metoxinamat+Titanium+Oxybenzon 1 Parasol Cream 20 gr SDM

K. ANTISEPTIK & DESINFEKTAN KULIT


Ichtamol 1 Ichtiyol-Zalf Tube 10% 15 gr Nufarindo

2 Betadine Solution 60ml Mahakam


Salep
3 Iodin Povidone Solution 30ml, 60ml Kimia Farma
4 Rivanol Solution 60ml Kimia Farma

Kalium Permanganat 1 PK Powder 5 gr

25
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
L. KASA MENGANDUNG OBAT
Framycetin Sulfat 1 Daryantull Pack Darya Varia

Kasa Polyester+Eco Honey+Glycerol 1 Sanoskin Melladerm Plus Tule Pack Interbat

Hydrocellular Poyurethane 1 Sanoskin Foam Pack Interbat

Collagen Sponge 1 Collacure Pack Nufarindo

M. OBAT KULIT LAIN


Cepalin Extra+Allantoin 1 Mederma Gel 20 gr Combiphar

Radix Stutellariae+Phelladendri Cartex+Rhiz 1 Mebo Cream 20 gr Combiphar

Anhydrous Lanolin+Isopropyl myristate 1 Decubal Cream 20 gr Actavis

Hypoallergenic ambiphilip cream base 1 Biocream Cream Merck

Eco honey+glycerin+propilene glicol+PEG 1 Sanoskin Melladerm Plus Gell Plus Interbat

Oxygen converted 1 Sanoskin Oxy Gell 30 gr Interbat

Daktarin Diapers Cream Bayer

XVII. ANESTESI LOKAL & UMUM

Bupivacaine heavy 1 Marcaine

Ketamine

XVIII. ANTI ALERGI & SISTEM IMUN

A. ANTI HISTAMIN DAN ANTI ALERGI


Loratadine 1 Alloris Syrup 10 mg SANBE

Loratadine Micronize 1 Claritin Tablet Schering

Cetirizine 1 Cetirizine Generik Tablet


2 Histrin Syrup Ferron
3 Falergi Tablet Fahrenheit
4 Cetinal Syrup Kalbe Farma
5 Intrizin Tablet Interbat
drop

Syrup
Bethametasone + Dexlorpheniramin 1 Celestamine Tablet Schering
Syrup
2 Cortamine Syrup Interbat
3 Colergis Tablet Dexa Medica
Syrup

Dexametasone + Dexchlorpheniramin 1 Dextamine Tablet Papros

Dimenthinden maleat 1 Fenistil Drop Novartis


Syrup

Chlortrimeton 1 CTM Generik Tablet

Dexametasone 1 Dexametasone Generik Tablet 0.5 mg


Injeksi 0.5 mg
2 Indexon Injeksi 0.5 mg Interbat

26
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Alkohol 70% 100 mL Molex ayus
Prednison 1 Prednison GeneriK Tablet 5 mg

Metil prednisolon 1 Metil Prednisolon GeneriK Tablet


2 Lameson Tablet 4mg, 8mg Lapi
3 Simdrol Tablet 4mg Simex
4 Hexilon Tablet 8mg Kalbe Farma
5 Medixon Injeksi 125 mg Ferron
tablet 4mg, 16mg
6 Prednicort Injeksi 125 mg/ml Otto

Triamcinolone acetonide 1 Flamicort Injeksi Dexa Medica

B. VAKSIN, ANTISERUM, & IMUNOLOGIKAL


-
C. IMUNOSUPRESAN
-

XIX. ANTIDOTUM DAN ZAT DETOKSIFIKASI

N-Acetylcysteine 1 Hidonac Infus 200mg/ml Zambon

Kalsium Polystyren Sulfonat 1 Kalitake Sachet 5 gr Dipa

Lantanum Karbonat 1 Fosrenol Tablet Kunyah 500 mg Fahrenheit

XX. LARUTAN INTRAVENA & LARUTAN STERIL LAIN

Albumin Manusia 1 Plasbumin 5% Infus 250ml Dipa


2 Octalbin 20% Infus 50ml, 100ml Kalbe Farma
3 Human Albumin Behring 20% Infus 50ml Dexa Medica
4 Albumin Human 20% Infus 100ml Kima Farma
5 Plasbumin 25% Infus 50ml, 100ml Dipa
6 Albuminar 25% Infus 100ml Dexa Medica

27
10 25,000 1
2 10,000 100
2 15,730 100

28
analtram
spendifen
genkolin

29
No. NAMA ALKES MERK HARGA

CATHETER INTRA VENA


1 IVENA IV 20G IVENA
2 SURFLO TERUMO 14 G TERUMO
3 SURFLO TERUMO 24 G TERUMO
4 SURFLO W 26 GX 19MM TERUMO
5 VASOFIX WING SAFETY B BRAUN 16 G B BRAUN
6 VASOFIX WING SAFETY B BRAUN 18 G B BRAUN
7 VASOFIX WING SAFETY B BRAUN 22 G B BRAUN
8 VENFLON BD 18 GA BD
9 VENFLON BD 20 GA BD
10 VENFLON BD 22 GA BD
CATHETER SPINAL
11 SPINAL NEEDLE WHIT INTRODUCER 25G B BRAUN
12 SPINAL NEEDLE WHIT INTRODUCER 27G B BRAUN
TROCARD CATHETER (CHEST TUBE)
13 TROCARD CATHETER NO 18 TROCARD
14 TROCARD CATHETER NO 20 TROCARD
15 TROCARD CATHETER NO 24 TROCARD
XCEL 5X100MM STABILITY SLEEVEE (CB5LT)
XCEL 11X100MM STABILITY SLEEVEE (CB11LT)
INFUSION SET
MACRO
16 CERTOFIX TRIO V1220 HFPCS B BRAUN
17 CERTOFIX TRIO V720PCS B BRAUN
18 INTRAFIX SAFESET (INFUSET MAKRO SAFETY) B BRAUN
19 TERUFUSION SOLUTION ADM. SET (MACRO) TERUMO
MICRO
20 INTRAFIX AIR PEDIATRIK (INFUS SET MICRO) B BRAUN
21 TERUFUSION PEDIATRIC SOL. ADM. SET (MICRO) TERUMO
BURET
22 WITH BURET (PUMP) TERUMO TERUMO
23 WITH BURET 100 ML JMS JMS
TRANFUSION SET
24 BLOOD SET (SANGOFIX ES)/TRANFUSION SET B BRAUN
BLOOD LANSET 26G OM ONEMED
BLOOD LANSET 28G OM ONEMED

25 TRANSFUSION SET (BLOOD 15 DPROS/ML) TERUMO TERUMO


THREE WAY
26 SURFLUG TERUMO (3 WAY) TERUMO
27 THREE WAY STOPCOCK WITH 10CM TUBE (LEURLOCK) JMS
SYRINGE
28 DISP SYRINGE 1 CC INSULIN - 27G X 1 TERUMO TERUMO
29 DISP SYRINGE 1 CC TUBERCULIN TERUMO
30 DISP SYRINGE 10 CC -21G X 1 1/2 TERUMO TERUMO
31 DISP SYRINGE 3 CC - 23G X 1 1/4 TERUMO TERUMO
32 DISP SYRINGE 5 CC -23G X 1 1/4 TERUMO TERUMO
33 DISP SYRINGE 20 CC TERUMO TERUMO
34 DISP SYRINGE 50 CC (CATHETER TIP) TERUMO TERUMO
35 DISP SYRINGE 50CC (EXENTRIC)TERUMO TERUMO
36 SYRING DISPOSABLE NEMOTO 100 ML NEMOTO
37 SYRINGE HEPARIN AGD TERUMO
NEEDLE
38 NEEDLE NO. 18 G TERUMO TERUMO
39 NEEDLE NO. 19 G TERUMO TERUMO
40 NEEDLE NO. 20 G TERUMO TERUMO
41 NEEDLE NO. 21 G TERUMO TERUMO
42 NEEDLE NO. 22 G TERUMO TERUMO
43 NEEDLE NO. 23 G TERUMO TERUMO
44 NEEDLE NO. 24 G TERUMO TERUMO
45 NEEDLE NO. 25 G TERUMO TERUMO
46 NEEDLE NO. 26 G TERUMO TERUMO
47 NEEDLE NO. 27 G TERUMO TERUMO
48 NEEDLE FLASHBACK NO. 22 BD
ETT
49 ETT CLEAR W/CUFF DISP NO. 4 1/2 RUSCH RUSCH
50 ETT CLEAR W/CUFF DISP NO. 4 RUSCH RUSCH
51 ETT CLEAR W/CUFF DISP NO. 5 1/2 RUSCH RUSCH
52 ETT CLEAR W/CUFF DISP NO. 5 RUSCH RUSCH
53 ETT CLEAR W/CUFF DISP NO. 6 1/2 RUSCH RUSCH
54 ETT CLEAR W/CUFF DISP NO. 6 RUSCH RUSCH
55 ETT CLEAR W/CUFF DISP NO. 7 1/2 RUSCH RUSCH
56 ETT CLEAR W/CUFF DISP NO. 7 RUSCH RUSCH
57 ETT CLEAR W/CUFF DISP NO. 8 1/2 RUSCH RUSCH
58 ETT CLEAR W/CUFF DISP NO. 8 RUSCH RUSCH
59 ETT CLEAR W/CUFF DISP NO. 9 RUSCH RUSCH
60 ETT CLEAR W/CUFF DISP NO.3 1/2 RUSCH RUSCH
61 ETT CLEAR W/CUFF DISP NO.3 RUSCH RUSCH
62 ETT CLEAR W/O CUFF NO.2 1/2 RUSCH RUSCH
63 ETT CLEAR W/O CUFF NO.2 RUSCH RUSCH
64 ETT CLEAR W/O CUFF NO.3 1/2 RUSCH RUSCH
65 ETT CLEAR W/O CUFF NO.3 RUSCH RUSCH
66 ETT CLEAR W/O CUFF NO.4 1/2 RUSCH RUSCH
67 ETT CLEAR W/O CUFF NO.4 RUSCH RUSCH
68 ETT CLEAR W/O CUFF NO.5 1/2 RUSCH RUSCH
69 ETT CLEAR W/O CUFF NO.5 RUSCH RUSCH
70 ETT CLEAR W/O CUFF NO.6 RUSCH RUSCH
71 ETT NON KING-KING NO. 5 RUSCH RUSCH
72 ETT NON KING-KING NO. 5,5 RUSCH RUSCH
73 ETT NON KING-KING NO. 6 RUSCH RUSCH
74 ETT NON KING-KING NO. 6,5 RUSCH RUSCH
75 ETT NON KING-KING NO. 7 RUSCH RUSCH
76 ETT NON KING-KING NO. 7,5 RUSCH RUSCH
77 ETT NON KING-KING NO. 8 RUSCH RUSCH
78 ETT NON KING-KING NO. 8,5 RUSCH RUSCH
79 ETT NON KING-KING NO.22 RUSCH RUSCH
FEEDING TUBE
80 FEEDING TUBE FR 10 (120 CM) JMS JMS
81 FEEDING TUBE FR 12 (120 CM) JMS JMS
82 FEEDING TUBE FR 15 (120 CM) JMS JMS
83 FEEDING TUBE FR 3 (40) JMS JMS
84 FEEDING TUBE FR 4 (40) JMS JMS
85 FEEDING TUBE FR 5 (120) JMS JMS
86 FEEDING TUBE FR 5 (40) JMS JMS
87 FEEDING TUBE FR 6 (40) JMS JMS
88 FEEDING TUBE FR 6 (80) JMS JMS
89 FEEDING TUBE FR 7 (120) JMS JMS
90 FEEDING TUBE FR 7 (40) JMS JMS
91 FEEDING TUBE FR 8 (120) JMS JMS
92 FEEDING TUBE FR 8 (40) JMS JMS
FOLLEY CATHETER
93 FOLLEY CATHETER FR 10 (PEDIATRIC) WRP WRP
94 FOLLEY CATHETER FR 12 (2 WAY) WRP WRP
95 FOLLEY CATHETER FR 14 (2 WAY) WRP WRP
96 FOLLEY CATHETER FR 16 (2 WAY) WRP WRP
97 FOLLEY CATHETER FR 18 (2 WAY) WRP WRP
98 FOLLEY CATHETER FR 20 (2 WAY) WRP WRP
99 FOLLEY CATHETER FR 22 (2 WAY) WRP WRP
100 FOLLEY CATHETER FR 24 (2 WAY) WRP WRP
101 FOLLEY CATHETER FR 26 (2 WAY) WRP WRP
102 FOLLEY CATHETER FR 8 (PEDIATRIC) WRP WRP
SELANG OKSIGEN
115 NASSAL CANULA ADULT COSMOMED
116 NASSAL CANULA NEONATUS COSMOMED
117 NASSAL CANULA PEDIATRIC COSMOMED
MASKER OKSIGEN
118 MASKER OKSIGEN ADULT COSMOMED
119 MASKER OKSIGEN ADULT BAG COSMOMED
120 MASKER OKSIGEN CHILD COSMOMED
121 MASKER OKSIGEN CHILD BAG COSMOMED
122 MASKER OKSIGEN PEDIATRIC COSMOMED
MASKER NEBULIZER
123 MASKER NEBULIZER ADULT COSMOMED
124 MASKER NEBULIZER CHILD COSMOMED
125 MASKER NEBULIZER PEDIATRIC COSMOMED
NASSAL TUBING
126 NASSAL TUBING 100MM BC182 MSU
127 NASSAL TUBING 70MM BC181 MSU
128 NASSAL PRONG 3.5 MM/2.0 MM MSU
129 NASSAL PRONG 4.0 MM/3.0 MM MSU
130 NASSAL PRONG 4.5 MM/4.0 MM MSU
131 NASSAL PRONG 5.0 MM/4.0 MM MSU
132 J TUBING 18" FILL TUBE MULIA HUSADA
STOMACH TUBE
133 STOMACH TUBE 14 FR (125CM) TERUMO TERUMO
134 STOMACH TUBE 16 FR (125CM) TERUMO TERUMO
135 STOMACH TUBE 18 FR (125CM) TERUMO TERUMO
SUCTION CATHETER
136 MUCUS EXTRACTOR FR 10 TERUMO
137 SUCTION CATHETER NO.10 IDEALCARE IDEALCARE
138 SUCTION CATHETER NO.12 IDEALCARE IDEALCARE
139 SUCTION CATHETER NO.14 IDEALCARE IDEALCARE
140 SUCTION CATHETER NO.16 IDEALCARE IDEALCARE
141 SUCTION CATHETER NO.8 IDEALCARE IDEALCARE
BENANG JAHIT
CAT GUT CHROMIC
142 CATGUT CHROMIC 2 SMI HR 45MM SMI
143 CATGUT CHROMIC 0 HR45MM REF2400145 SMI
144 CATGUT CHROMIC 2/0 REF2350126 SMI ROUND SMI
145 CATGUT CHROMIC 2/0 SMI REF 2350130 SMI
CATGUT CHROMIC 2/0 + JARUM (BOX) ONEMED
CATGUT CHROMIC 3/0 + JARUM (BOX) ONEMED
146 CATGUT CHROMIC 3/0 REF 2300126 SMI ROUND SMI
147 CATGUT CHROMIC O REF 2400137 SMI SMI
148 CATGUT CHROMIC USP 0 (100M) PER METER SMI
149 CATGUT CHROMIC USP 1 (75M) PER METER SMI
150 CATGUT CHROMIC USP 2 (50M) PER METER SMI
151 CATGUT CHROMIC USP 2/0 (100M) PER METER SMI
152 CATGUT CHROMIC USP 3 (50M) PER METER SMI
153 CATGUT CHROMIC USP 3/0 (100M) PER METER SMI
154 CATGUT CHROMIC USP 4 (30M) PER METER SMI
155 CATGUT CHROMIC USP 4/0 (100M) PER METER SMI
156 CHROMIC 1 CG-905 SURGICA
157 CHROMIC 2/0 G123T ETHICON
158 CHROMIC 2/0 GG-123 SURGICA
159 CHROMIC 2/0 W913H ETHICON
160 CHROMIC 4/0 G181T ETHICON
161 CHROMIC GUT 1 905T ETHICON
CATGUT PLAIN
165 CATGUT PLAIN 2/0 W1872T ETHICON
166 CATGUT PLAIN 3/0 H818T ETHICON
167 CATGUT PLAIN 4/0 H819T SMI
CATGUT PLAIN 2/0 + JARUM (BOX) ONEMED
CATGUT PLAIN 3/0 + JARUM (BOX) ONEMED
168 CATGUT PLAIN USP 0 (100M) PER METER SMI
169 CATGUT PLAIN USP 1 (75M)SMI SMI
170 CATGUT PLAIN USP 2 (50M) PER METER SMI
171 CATGUT PLAIN USP 2/0 (100M) PER METER SMI
172 CATGUT PLAIN USP 2/0 1350126SMI SMI
173 CATGUT PLAIN USP 3 (50M) PER METER SMI
174 CATGUT PLAIN USP 3/0 (100M) PER METER SMI
175 CATGUT PLAIN USP 4 (30M) PER METER SMI
176 CATGUT PLAIN USP 4/0 (100M) PER METER SMI
DEXON
177 DEXON II 1 (9828-71) ETHICON
178 DEXON II 3/0 (9619-41) ETHICON
179 DEXON S 3/0 (7216-41) ETHICON
ETHIBOND
180 ETHILON 10-0 W 1718 ETHICON
181 ETHILON 8/0 1716G ETHICON
PROLEN
182 PROLENE BLUE 0 W 486 ETHICON
183 PROLENE BLUE 5/0 8618G ETHICON
184 PROLENE BLUE 7/0 3/8 ETHICON
185 PROLENE BLUE 7/0 8702H ETHICON
186 PROLENE USP 3/0 W 538 ETHICON
187 PROLENE USP 4/0 W 525 ETHICON
188 PROLENE USP 5/0 W 527 ETHICON
189 PROLENE USP 6/0 W 523 ETHICON
190 PROLENE USP 6/0 W 8706H ETHICON
PREMILENE
191 PREMILENE 2/0 DS 24 B BRAUN
192 PREMILENE 3/0 DS 19 B BRAUN
193 PREMILENE 4/0 DS 19 B BRAUN
SILK
194 MERSILK 3/0 W2511T ETHICON
195 MERSILK 4/0 W 2505T ETHICON
196 SILK 3/0 1124-41 (T 16) SURGIKA
197 SILK BLACK 0 HR 37 MM 8350137 SMI
198 SILK BLACK 2/0 SMI REF 8300126 ROUND SMI
199 SILK BLACK 3/0 SACHET SMI ROUND SMI
200 SILK BLACK O REF8350130 SMI
201 SILK BLACK PFR 2/0 (100M) PER METER ENSEVALL
202 SILK BLACK USP 0 (100 M) PER METER SMI
203 SILK BLACK USP 1 (100 M) PER METER SMI
204 SILK BLACK USP 2 (100 M) PER METER SMI
205 SILK BLACK USP 2/0 (100 M) PER METER SMI
206 SILK BLACK USP 3 (80 M) PER METER SMI
207 SILK BLACK USP 3/0 (100 M) PER METER SMI
208 SILK BLACK USP 4 (60 M) PER METER SMI
209 SILK BLACK USP 4/0 (100 M) PER METER SMI
SURGI
210 SURGILON 2/0 1934-53 SMI
211 SURGILON 3/0 1934-43 SMI
SURGICAL BLADE
235 SURGICAL BLADE NO. 5 AESCULAP
236 SURGICAL BLADE NO. 11 AESCULAP
237 SURGICAL BLADE NO. 12 AESCULAP
238 SURGICAL BLADE NO. 15 AESCULAP
239 SURGICAL BLADE NO. 20 AESCULAP
240 SURGICAL BLADE NO. 22 AESCULAP
241 SURGICAL BLADE NO.14 AESCULAP
242 SURGICAL BLADE NO.21 AESCULAP
243 SURGICAL BLADE NO.23 AESCULAP
244 SURGICAL BLADE NO.24 AESCULAP
JARUM JAHIT
245 JARUM JAHIT GR 11 SMI
246 JARUM JAHIT GR 12 SMI
247 JARUM JAHIT GR 13 SMI
248 JARUM JAHIT GR 15 SMI
249 JARUM JAHIT GR 15 SMI
250 JARUM JAHIT GR 5 SMI
251 JARUM JAHIT GR 6 SMI
252 JARUM JAHIT GR 8 SMI
253 JARUM JAHIT GR 9 SMI
254 UNIMED GR 10 UNIMED
255 UNIMED GR 11 UNIMED
256 UNIMED GR 12 UNIMED
257 UNIMED GR 13 UNIMED
258 UNIMED GR 14 UNIMED
259 UNIMED GR 15 UNIMED
260 UNIMED GR 3 UNIMED
261 UNIMED GR 5 UNIMED
262 UNIMED GR 6 UNIMED
263 UNIMED GR 7 UNIMED
264 UNIMED GR 8 UNIMED
265 UNIMED GR 9 UNIMED
266 UNIMED GT 10 UNIMED
267 UNIMED GT 11 UNIMED
268 UNIMED GT 12 UNIMED
269 UNIMED GT 13 UNIMED
270 UNIMED GT 14 UNIMED
271 UNIMED GT 15 UNIMED
272 UNIMED GT 16 UNIMED
273 UNIMED GT 3 UNIMED
274 UNIMED GT 5 UNIMED
275 UNIMED GT 6 UNIMED
276 UNIMED GT 7 UNIMED
277 UNIMED GT 8 UNIMED
278 UNIMED GT 9 UNIMED
279 UNIMED PB 3 UNIMED
280 UNIMED PB 4 UNIMED
281 UNIMED PB 5 UNIMED
282 UNIMED PB 6 UNIMED
JARUM EXTERPATIE
283 JARUM EXTERPATIE
SCREW
284 CORTECAL SCREW 4,5 MM (SYNTHES) 24 MM
285 CORTECAL SCREW 4,5 MM (SYNTHES) 26 MM
286 CORTECAL SCREW 4,5 MM (SYNTHES) 28 MM
287 CORTECAL SCREW 4,5 MM (SYNTHES) 30 MM
288 CORTECAL SCREW 4,5 MM (SYNTHES) 32 MM
289 CORTECAL SCREW 4,5 MM (SYNTHES) 34 MM
290 CORTECAL SCREW 4,5 MM (SYNTHES) 36 MM
291 CORTICAL SCREW 4.5,L14 AAP BERLIN
292 CORTICAL SCREW 4.5,L16 AAP BERLIN
293 CORTICAL SCREW 4.5,L18 AAP BERLIN
294 CORTICAL SCREW 4.5,L22 AAP BERLIN
295 CORTICAL SCREW 4.5,L24 AAP BERLIN
296 CORTICAL SCREW 4.5,L26 AAP BERLIN
297 CORTICAL SCREW 4.5,L30 AAP BERLIN
298 CORTICAL SCREW 4.5,L36 AAP BERLIN
299 CORTICAL SCREW 4.5,L40 AAP BERLIN
WIRE
300 CERCLAGE WIRE 6113-001 1,0MM SURGIVAL
301 CERCLAGE WIRE 6113-002 1,2MM SURGIVAL
302 CERCLAGE WIRE 6113-003 1,5MM SURGIVAL
303 KIRSCHNER WIRE 1,5 MM L=310 MM SURGIVAL
304 KIRSCHNER WIRE 1,8 MM W/TROCAR TIP L280 MM REF 292.190.10
305 KIRSCHNER WIRE 2,5 MM L=310 MM SURGIVAL
306 KIRSCHNER WIRE 2,5 MM W/TROCAR TIP L280 MM REF 292.190.10
307 KIRSCHNER WIRE 2.0MM W/TROCAR TIP L280 REF 292.210.10
308 KIRSCHNER WIRE 3.0MM W/TROCAR TIP L280MM REF 292.310.10
309 KIRSCHNER WIRE GLOMED UK : 1,5
310 KIRSCHNER WIRE GLOMED UK : 2,0
311 KIRSCHNER WIRE GLOMED UK : 2,5
KAPAS
312 KAPAS BERLEMAK PER 10 GR DRC
313 KAPAS BUNGA BIRU PER 10 GR BUNGA BIRU
314 KAPAS PEMBALUT PER 10 GR DRC
ALAT VERBAN
315 CREPE BANDAGE 3" BSN
316 CREPE BANDAGE 4" NEBA
317 CREPE BANDAGE 6" BSN
318 KASSA HIDROPHIL 16X16
319 KASSA PEMBALUT HIDROPHIL 4 X 5 CM DRC
320 KASSA BEDAH 10 LBR PER BUNGKUS
321 KASSA OBGYN 10 LBR PER BUNGKUS
322 KASSA MATA PER PCS
323 KASSA TAMPON BULAT PER PCS
324 KASSA TAMPON PANJANG 20CMX 20 CM
325 KASSA +KAPAS 20 CM X 20 CM STERIL PER BUAH
326 KASSA 20 CM X 20CM STERIL PER 10 LBR
327 LEUKOBAND / SOFFBAND 3" BSN
328 LEUKOBAND / SOFFBAND 4" AMPON
329 LEUKOBAND / SOFFBAND 6" BSN
330 LEUKODUR 3" BSN
331 LEUKODUR 4" BSN
332 LEUKODUR 6" BSN
333 TENSOCREEPE 3" BSN
334 TENSOCREEPE 4" BSN
335 TENSOCREEPE 6" BSN
336 TRICOFIX 4CM X 10M BSN
337 TRICOFIX 6CMX10M BSN
338 TRICOFIX 8CM X 10M BSN
3 KASSA UCOLON RSBK
4 BIG GAAS RSBK
5 KASSA UCOLON RSBK
6 BIG GAAS RSBK
7 RANSEL VERBAND CHILD RSBK
8 RANSEL VERBAND ADULT RSBK
PLASTER
335 FIRST AID PLASTER (HANSAPLAST)
336 FIXOMUL 15 CM X 5 M PER 10 CM BSN
337 FIXOMUL TRANSPARANT PER 10 CM
338 LEUKOMED T PLUS BSN
339 LEUKOMED-IV BSN
340 LEUKOMED-IV FILM BSN
341 LEUKOPLAST 1625 H (7,5 CM X 4,5)/10 CM BSN
342 LEUKOPOR 1,25 CM X 5 CM BSN
343 LEUKOPOR 1,25CM X 9,2M + DISPENSER BSN
344 LEUKOPOR 1,25CM X 9.2M BSN
345 LEUKOPOR 2,5 CM X 9.2 + DISPENSER BSN
346 LEUKOPOR 2.50CM X 9.2N BSN
347 POSTOFIX 10 X 15 CM PER PCS GDM
348 POSTOFIX 10 X 25 CM PER PCS GDM
349 TENSOPLAST STK ADULT BSN
350 TENSOPLAST STK CHILD BSN
3 FIRST AID PLASTER (HANSAPLAST)
4 LEUKOPLAST 1625 H (7,5 CM X 4,5)/10 CM BSN
LARUTAN (DESINFEKTAN)
351 ALKOHOL 70% 10 ML MOLEX AYUS MOLEX AYUS
352 ALKOHOL 96% 10 ML BRATACO
353 ALKOHOL SWAB PER PCS BD
ALKOHOL SWAB ONEMED
354 BETADINE 10 ML
355 DETTOL LIQUID NO.24 100 ML
356 FORMALIN CAIR 1000ML BRATACO
357 GLYSERIN 10 ML BRATACO
358 H2O2 3% 10 ML
359 H2O2 50% 10ML
360 RIVANOL 100 ML
SUPPORTING MEDIK
361 ACTIMOVE CERVICAL COLAR XS BSN
362 ACTIMOVE CERVICAL COLAR S BSN
363 ACTIMOVE CERVICAL COLAR M BSN
364 ACTIMOVE CERVICAL COLAR L BSN
365 ACTIMOVE CERVICAL COLAR XL BSN
366 AVTIMOVE VERTEBRACE S/M/L BSN
367 ACTIMOVE LUMBOCARE MOTION S BSN
368 ACTIMOVE LUMBOCARE MOTION M BSN
369 ACTIMOVE LUMBOCARE MOTION L BSN
370 ACTIMOVE LUMBOCARE MOTION XL BSN
371 ACTIMOVE MITELLA ECO ARM SLING S ONEMED
372 ACTIMOVE MITELLA ECO ARM SLING M ONEMED
373 ACTIMOVE MITELLA ECO ARM SLING L ONEMED
374 ACTIMOVE MITELLA ECO ARM SLING XL BSN
375 CERVICAL COLAR SUPPORT
376 LUMBAR SUPPORT L
377 LUMBAR SUPPORT M
378 LUMBAR SUPPORT S
379 LUMBAR SUPPORT XL
380 MITELLA SEGITIGA IBON
ALAT PELINDUNG DIRI
381 APPRON 1250 MM (SHCORT) AMMEDA
382 APPRON DISP. PLASTIC 1400MM (SHCORT) AMMEDA
383 FACE MASK 3PLY GP CARE
384 FACE MASK MIKA HIJAU
385 HANDSCOEN PANJANG COTEX COTEX
386 HANDSCOEN PLASTIC DISP. L AMMEDA
387 HANDSCOEN PLASTIC DISP. M AMMEDA
388 HANDSCOEN PLASTIC DISP. S AMMEDA
389 HANDSCOEN STERIL SIZE 6 GAMEX
390 HANDSCOEN STERIL SIZE 6,5 GAMEX
391 HANDSCOEN STERIL SIZE 7 GAMEX
392 HANDSCOEN STERIL SIZE 7,5 GAMEX
393 HANDSCOEN STERIL SIZE 8 GAMEX
394 HANDSCOEN STERIL SIZE 8,5 GAMEX
395 LATEX EXAMINATION GLOVE SIZE L COSMOMED
396 LATEX EXAMINATION GLOVE SIZE M COSMOMED
397 LATEX EXAMINATION GLOVE SIZE S COSMOMED
398 TOPI OPERASI WANITA/PRIA COSMOMED
IUD
399 COPPER T CU 380 (LIMAS)
400 NOVA T
VAKSIN
401 VAKSIN ANTI BISA ULAR BIO FARM
402 VAKSIN ANTI TETANUS 1500 U.I ASKES BIO FARM
403 VAKSIN ANTI TETANUS 1500 U.I REG BIO FARM
404 VAKSIN BCG 20 DS BIO FARM
405 VAKSIN CERVARIX INJ
406 VAKSIN DPT BIO FARM
407 VAKSIN DPT-HB KOMBINASI BIO FARM
408 VAKSIN EUVAX B ADULT 1 ML (HEP. B) SANOFI
409 VAKSIN EUVAX B ADULT MD 10 ML (HEP. B) SANOFI
410 VAKSIN EUVAX B PEDIATRIC 0,5 ML SANOFI
411 VAKSIN JERAP TETANUS BIO FARM
412 VAKSIN POLIO + PIPET 10 DS/ 1 ML BIO FARM
413 VAKSIN PPD 2 TU BIO FARM
VAKSIN PPD 2 TU BIO FARM
414 VAKSIN TRIMOVAX INJ SANOFI
415 VAKSIN VERORAB INJ SANOFI
USER

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STANDAR CAIRAN INFUS

NO KOMPOSISI NAMA PRODUK FARMASI

A KRISTALOID
a. NACL 0,9% 1 NACL 0,9% 500 ML BPJS OTSUKA
2 NACL 0.9% 500ML REGULER OTSUKA

3 NACL 1000 ML REG WIDATRA


4 NACL 500ML BPJS WIDATRA
5 NACL 500ML REG WIDATRA
6 NACL NSI TWIST OF 1000 ML WIDATRA

7 INFUSAN NS DP 500ML (SOFT BAG) SANBE


8 INFUSAN NS DP 250 ML SANBE

b. Ringer 9 RL BPJS OTSUKA


10 RL REGULER OTSUKA
11 ASERING 5 500 ML OTSUKA
12 ASERING 500 ML REGULER OTSUKA
13 ASERING 500ML BPJS OTSUKA

14 INFUSAN RL DP 500ML SANBE


15 INFUSAN RING-AS DP 500ML SANBE

B KOLOID
16 WIDAHES 130 WIDATRA
17 WIDAHES 130UNICAP REGULER WIDATRA
18 WIDAHES REGULER WIDATRA

19 GELOFUSAL INF DEXA

20 GELOFUSIN 500ML BPJS B BRAUN


21 GELOFUSIN 500ML REGULER B BRAUN

C DEXTROSE
22 DEXTROSE 10% 500 ML OTSUKA
23 DEXTROSE 40% 25ML OTSUKA
24 DEXTROSE 5% 100 ML OTSUKA
25 DEXTROSE 5% 500 ML BPJS OTSUKA
26 DEXTROSE 5% 500 ML REG OTSUKA
27 DEXTROSE 5% NS REGULER OTSUKA

28 DEXTROSE 10% WIDATRA

29 INFUSAN D5 500 ML DP SANBE


30 INFUSAN D5 250 ML DP SANBE
31 INFUSAN D10 500 ML DP SANBE

D MANITOL
32 MANITOL 20% BPJS OTSUKA
33 MANITOL 20% REGULER OTSUKA

34 INFUSAN M20 500 ML DP SANBE

E CAIRAN PELARUT
35 AQUABIDEST 1000 ML OTSUKA

36 AQUABIDEST IKAFARM /50ML IKAFARM

37 AQUASTERIL 25 ML BPJS OTSUKA


38 AQUASTERIL 25ML REGULER OTSUKA

39 AQUASTERIL 1000 ML BPJS WIDATRA


40 AQUASTERIL 1000 ML REG WIDATRA

F CAIRAN RUMATAN
1. DEXTROSE + ELEKTROLIT 41 KA-EN 1B OTSUKA
42 KA-EN 3A OTSUKA
43 KA-EN 4B OTSUKA
44 KA-EN MG 3 SOL OTSUKA
45 KAEN 3B 500 ML ASKES OTSUKA
46 KAEN 3B 500ML REGULER OTSUKA
47 KAEN 4A OTSUKA

48 D5 1/4 NS ASKES WIDATRA


49 D5 1/4 NS REG WIDATRA
50 D5 NS 500 ML WIDATRA

51 INFUSAN D5 + 1/2 NS 500 ML DP SANBE


52 INFUSAN D5 + 1/4 NS 500 ML DP SANBE
53 INFUSAN R + D 500 ML DP SANBE
54 TRIDEX 27 A 500 ML DP SANBE
55 TRIDEX 27 B 500 ML DP SANBE
56 TRIDEX 100 500 ML DP SANBE
US

HARGA USER

Rp 5,827 SEMUA KELAS


Rp 13,900 SEMUA KELAS

Rp 18,900 SEMUA KELAS


Rp 5,827 SEMUA KELAS
Rp 12,698 SEMUA KELAS
b SEMUA KELAS

KELAS
KELAS

Rp 6,500 SEMUA KELAS


Rp 13,900 SEMUA KELAS
Rp 24,200 SEMUA KELAS
Rp 24,700 SEMUA KELAS
Rp 8,769 SEMUA KELAS

Rp 17,800 KELAS
Rp 20,000 KELAS

Rp 165,375 SEMUA KELAS


Rp 60,488 SEMUA KELAS
Rp 164,325 SEMUA KELAS

SEMUA KELAS

KELAS
KELAS

Rp 6,818 SEMUA KELAS


SEMUA KELAS
SEMUA KELAS
Rp 6,273 SEMUA KELAS
Rp 13,900 SEMUA KELAS
Rp 16,100 SEMUA KELAS

Rp 15,208 SEMUA KELAS

KELAS
KELAS
KELAS

Rp 25,705 SEMUA KELAS


SEMUA KELAS

SEMUA KELAS

SEMUA KELAS

SEMUA KELAS

Rp 2,600 SEMUA KELAS


SEMUA KELAS

SEMUA KELAS
SEMUA KELAS

Rp 9,273 SEMUA KELAS


Rp 10,285 SEMUA KELAS
Rp 22,000 SEMUA KELAS
Rp 24,000 SEMUA KELAS
Rp 10,285 SEMUA KELAS
Rp 24,000 SEMUA KELAS
Rp 22,000 SEMUA KELAS

Rp 9,658 SEMUA KELAS


Rp 14,820 SEMUA KELAS
Rp 13,734 SEMUA KELAS

Rp 18,550 SEMUA KELAS


Rp 18,350 SEMUA KELAS
Rp 18,650 SEMUA KELAS
Rp 10,825 SEMUA KELAS
Rp 10,825 SEMUA KELAS
Rp 10,330 SEMUA KELAS
NO NAMA OBAT Farmasi

1 Actifed Sy merah
2 Actifed Sy hijau
3 Actifed Sy Kuning
4
5 Acyclofir 200 mg
6 Acyclofir 400 mg
7 Acyclofir salf
8 Albotil
9 Alfara sy
10 Alfara Tab
11 Alkohol 1L
12 Alkohol 100ml
13 Alletrol tetes mata
14 Allopurinol
15 Ambeven
16 Ambroxol sy
17 Ambroxol Tab
18 Amlodipine 10 mg
19 Amlodipine 5 mg
20 Amoxicilin sy
21 Amoxicilin Tab
22 Ampicilin
23 Anacetin sy
24 Andalan laktasi
25 Albendazol 40mg
26 Antalgin
27 Antasida sy
28 Antasida Tab
29 Antimo
31 Aquadest
32 Asam folat generic
33 Asam Mefenamat Tab
34 Asam Traneksamat
35 Aspilet
36 B com C Tab
37 B comp
38 B1
39 B12
40 B6@250
41 Baby cough sy
42 Balsem Lang
43 Benodon inj
44 Bromhexin HCl
45 Betadin 15ml
46 Betadine 30 ml
47 Betadine 60 ml
48 Betadin 1L
49 Betametason salf
50 Betason N salf
51 Bioplasenton salf
52 Bisolvon sy
53 Bodrex migra
54 Burnazim salf
55 Buskopan inj
56 Buskopan Tab
57 Bye Bye Fiver anak
58 Calortusin
59 Captopril 12.5 mg
60 Captopril 25 mg
61 Cataflam Tab
62 Caviplex drop
63 Caviplex Tab
64 Cefadroxil sy
65 Cefadroxil Tab
66 Cefadroxil Tab 250 mg
67 Cefixim sy
68 Cefixim Tab/50
69 Cek asam urat nesco
70 Cek gula darah nesco
71 Cek kolesterol nesco
72 Cek HB
73 Cetirizine
74 Cetirizine sy
75 Chloramfenicol Tab
76 Chor Ethil/Ethyl Chlorid
77 Cimetidin
78 Cipro
79 Citocetin sy
80 Clindamicyn 150 mg
81 Clyndamicyn 300 mg
82 Counterpaint cool
83 Counterpaint 15g
84 Counterpaint 30g
85 Coparcetin sy
86 Cotri sy
87 Cotri Tab
88 CTM Kaleng
89 Combivent
90 Curvit Sy
91 Cyclo Gestin/Harmony
94 Cyclofem inj
95 Daryantule
96 Della Inj
97 Depo inj
98 Dexa inj
99 Dexametazon Kaleng
100 Dexametazon strip
101 Dexanta
102 Dextral sy
103 Dextral Tab
104 Dextrose 5%
105 Domperidom sy
106 Domperidom Tab
107 Durex
108 Dumin 250 supp
109 Dumin supp
111 Eferison Tab
112 Ergotamin maleat
113 Epineprin Inj
114 Erla salf mata
115 Erla tetes mata
116 Erla tetes telinga
117 Erytromicyn sy
118 Erytromicyn Tab
119 Etabion
120 Etadexta
121 Etaflusin sy
122 Fatigon spririt
123 Fenaren Tab
124 FG troges
125 Flucadex
126 Flunarizin tab
127 Flutamol Tab
128 Flutop C sy
129 Folaplus
130 Folavit
131 Forumen TT
132 Freshcare roll
133 Furosemid
134 Furosemid inj
135 Gentamisin salf mata
136 Gentamicyn salf
137 GG
138 Glibensamid
139 Glimepirid 1 mg
140 GOM
141 Grafaclor
142 Griseofulvin Tab
143 Guanistrep sy
144 Hansaplast strip
145 H2O2 1L
146 HCG
147 HCT
148 Hemorogard Tab
150 Hepagard Tab
151 Hidrocortiosn salf
152 Hipavik 5x5cm
153 Histigo @30
154 Iafed Tab
155 Ibuprofen sy
156 Ibuprofen Tab
157 Ificold sy
158 Iktiol salf
159 ISDN tab
160 Imbos Tab/50
161 Insto TM
162 Intunal F
163 Iodine 30ml
164 Itramol sy
165 Kalium Diklofenak
166 Kalmicetin salf
168 Kalpanax
169 Kalsium Lactate
170 Kanamicyn inj
172 Kenalog salf
173 Ketoconazole Salf
174 Ketokonazole Tab/50
175 Ketorolac inj
176 Kid Cought sy
177 Laserin dewasa
178 Lakto B
179 Lanadexon
180 Lanamol sy
181 Lansoprazole
182 Lidocain Inj/10
183 Loperamid
184 Loratadine/50
186 Mefinal tab
187 Mecobalamin
188 Meloxicam Tab 15mg
189 Metergin inj
190 Maltiron tab
191 Metformin
192 Metil prednison
193 Metil Prednison 8mg
194 Metronidazole sy
195 Metronidazole Tab
196 Mexamin Tab
197 Mexon
198 Miconazole salf
199 Microgynon pil KB
200 Microlax supp
201 Minyak kayu Putih 60 mL
202 Mylanta besar sy
203 Mylanta kecil
204 Mixagrif
205 Molagit
206 Molexflu sy
207 Molexflu Tab
208 Muliavit sy
210 NaCL
212 Natrium diklofenak Tab
213 Neprolid
214 Neuralgin
215 Neurobion inj
216 Neurodex
218 Nistatin drop
219 Nifedipine
220 Nistatin supp
221 Novadiar Sy
222 Novadril Sy
223 Novagesic Tab
224 Novakalk
225 Novamagh sy
226 Novastan
227 Novatrim sy
228 Novatrim Tab
229 Novatusin sy
230 OBH cito
231 OBH comby sy
232 Omecough sy
233 Omegavit
234 Omegdiar sy
235 Omegdiar Tab
236 Omegesic Tab
237 Omegtrim sy
238 Ondan inj
239 Omemox sy
240 Omemox Tab
241 Omeprazole/30
242 Ometidryl sy
243 Omeroxol sy
245 Omevomid sy
246 Omevomid Tab
247 Ondansentron
248 Oralit
249 Oxytetra salf kulit
250 Oxytetra salf mata
251 Pacdin Cough sy
252 Panadol biru
253 Panadol merah
254 Papaverin
255 Paracetamol Drop
256 Paracetamol sy
258 Paracetamol Tab Kaleng
259 Paracetamol Tab strip
260 Panadol hijau
261 Pil BKKBN
262 Paratusin
263 Pehacain inj
264 Pirantel tab
265 Piroxicam
266 Pitogin inj
267 Promagh
268 Prednison
269 Premolud
270 Primtrakol sy
271 Pritavit
272 Procet Sy
273 Procet Tab
274 Promagh
275 Proris Supp
276 Pulmicort
277 Ranitidine inj
278 Ranitidine Tab
279 Reco tetes mata
280 Rinos Tab
281 Rivanol 100 ml
282 RL
283 Redoxon
284 Salbutamol 2 mg
285 Salbutamol 4 mg
286 Salicyl Talk bedak
287 Sanmol drop
288 Sanmol sy
290 Sanmol Tab
291 Scabimit salf
292 Scopma
293 Siladex Sy biru
294 Silk saset
295 Simvastatin 10 mg
296 Simvastatin 20 mg
297 salep 24
298 Spasminal
299 Spuit 20cc
300 Spuit 3cc
302 Stesolid 5 mg
303 Stomagh sy
305 Stomagh Tab
306 Sulfas Ferosus/SF
307 Sultrimix Tab
308 Superhoid Supp
309 Tamaprofen sy
310 Tempra Sy
311 Triaminic batuk berdahak
312 Termagon
313 Tera-F
314 Tremenza syrup
315 Transamin
316 Tremenza
316 Triclofem
317 Trifamicetin
Trombofob
Ultrogeston
Ventolin nebu
Vickz formula 44 100 ml
Vipcold sy
Vit A merah
Vit C
Vit Cur sy
Vit K inj
Vit K Tab
Vitacimin
Vitazym
Vometa drop
Xello Inj
Zenirex Sy
Zinc
Woods expectorant
Woods merah
mebo salf
Vicks inhaler
Vicks vaporub
Sensitif
Masker Jilbab
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi
4 Magtral Susp Otto
2 Musin Susp 120 cc & 60 cc Otto
4 Rocer Capsul 20 mg Otto
Hyoscine N B + Paracetamol 1 Scopamin Plus Tablet Otto
Metoclorpramide 4 Piralen Injeksi 10 mg/2 ml Otto
Asam tranexamat 2 Transamin Injeksi 250 mg & 500 mg Otto
Tablet 250 mg & 500 mg
Maprotiline HCl 1 Tilsan Tablet 25 mg Otto
2 Valeptik Tablet 250 mg Otto
Paracetamol 3 Ottopan Drop 100 mg/ml Otto
Paracetamol+Tramadol 1 Tramifen Tablet Otto
Serapeptase 2 Dansera Tablet Otto
Lincomycin 2 Biolincom Capsul 500 mg Otto
Syrup 250 mg /5 ml
Sildenafil 1 Viajoy Capsul 50 mg Otto
Bonistein+Ca+VitK+Vit D3 1 Hi-Bone Tablet Otto
2 Visebad Drop Otto
Metil prednisolon 6 Prednicort Injeksi 125 mg/ml Otto

62
Jumlah Kemasan @HARGA ISIAN HARGA

63
DAFTAR HARGA PT. SANBE FARMA
NO NAMA PRODUK KOMPOSISI JumlahKemasan HNA ISIAN HNA/Satuan harga
1 Acetin 600 tab effervescent N-acetylcistein 600 mg Tube 84,100 1 84,100
2 Acran 150 mg film-coated tablet Ranitidin 150 gen 3 Box 136,800 30 4,560 410,400
3 Acran 300 mg film-coated caplet Ranitidin 300 gen 3 Box 199,950 30 6,665 599,850
4 Acran Injeksi Ranitidin inj gen 5 Box 96,600 5 19,320 483,000
5 Aldisa SR capsule Loratadin + Pseudoefedrin gen 2 Box 231,000 50 4,620 462,000
6 Alloris syrup Loratadin syr gen 5 Botol 50,000 1 50,000 250,000
7 Amoxsan 250 mg dispersible tablet Amoksisilin disp tab gen Box 130,000 100 1,300 0
8 Amoxsan 500 mg capsule Amoksisilin 500 gen Box 302,000 100 3,020 0
9 Amoxsan dry syrup Amoksisilin DS gen 20 Botol 20,710 1 20,710 414,200
10 Amoxsan forte dry syrup Amoksisilin FDS gen Botol 29,535 1 29,535 0
11 Amoxsan injeksi Amoksisilin inj gen 1 Box 207,100 10 20,710 207,100
12 Amoxsan Pediatric drop Amoksisilin Drop gen 10 Botol 20,710 1 20,710 207,100
13 Baquinor forte film- coated caplet Siprofloxacin 500 gen 2 Box 252,000 20 12,600 504,000
14 Baquinor infus Siprofloxacin 200 mg/100 ml infus gen 3 Fls 215,100 1 215,100 645,300
15 Becom-C film-coated caplet Vitamin B comp dan vit C gen 5 Box 123,000 100 1,230 615,000
16 Becom-Zet film-coated caplet Multivitamin + mineral Z gen 5 Box 164,000 100 1,640 820,000
17 Biosanbe capsule Kapsul tambah darah gen 5 Box 92,500 100 925 462,500
18 Braxidin film-coated tablet Anti spasmodik tab gen 5 Box 100,000 100 1,000 500,000
19 Bufect film coated tablet Ibuprofen 200 gen Box 61,500 100 615 0
20 Bufect Forte Suspensi Ibuprofen 200 mg/5 ml gen 10 Botol 19,000 1 19,000 190,000
21 Bufect Suspensi Ibuprofen 100 mg/5 ml gen 10 Botol 13,450 1 13,450 134,500
22 Cefat 500 mg capsule Sefadroksil 500 mg gen 1 Box 965,000 100 9,650 965,000
23 Cefat dry syrup Sefadroksil DS gen 10 Botol 39,700 1 39,700 397,000
24 Cefat forte dry syrup Sefadroksil FDS gen 10 Botol 68,300 1 68,300 683,000
25 Cinam serbuk injeksi steril Ampicilin 1gr + sulbactam 0,5 gr gen 2 Vial 132,500 1 132,500 265,000
26 Claneksi film-coated caplet Ko-amoksiklav cpt gen 2 Box 335,250 30 11,175 670,500
27 Claneksi forte dry syrup Ko-amoksiklav FDS gen 5 Botol 65,350 1 65,350 326,750
28 Claneksi serbuk injeksi steril Ko-amoksiklav inj gen 1 Box 534,000 6 89,000 534,000
29 Colsancetine injeksi Kloramfenikol inj gen 1 Box 94,800 10 9,480 94,800
30 Elkana suspensi Multivitamin dan kalsium syr gen 10 Botol 19,850 1 19,850 198,500
31 Erysanbe 250 mg capsule Eritromisin 250 cps gen 3 Box 128,000 100 1,280 384,000
32 Erysanbe 500 mg film-coated caplet Eritromisin 500 caplet gen 2 Box 246,000 100 2,460 492,000
33 Erysanbe dry syrup Eritromisin DS gen 10 Botol 20,400 1 20,400 204,000
34 Glybotic 250 injeksi Amikasin 250 mg/2 ml 2 Box 365,800 4 91,450 731,600
35 Glybotic 500 injeksi Amikasin 500 mg/2 ml 2 Box 633,800 4 158,450 1,267,600
36 Merosan 0.5 gr injeksi Meropenem 0,5 gr inj gen 2 Vial 255,900 1 255,900 511,800
37 Merosan 1 gr injeksi Meropenem 1 gr inj gen 2 Vial 499,600 1 499,600 999,200
38 Mezatrin 250 mg capsule Azhitromisin 250 cps gen 1 Box 402,900 30 13,430 402,900
39 Mucohexin elixir Bromheksida syr gen 10 Botol 15,200 1 15,200 152,000
40 Mucohexin tablet Bromheksida tab gen 3 Box 46,000 100 460 138,000
41 Nolipo 500 capsule Linkomisin 500 gen 1 Box 441,000 100 4,410 441,000
42 Nymiko suspensi drops Nystatin susp gen 10 Botol 30,500 1 30,500 305,000
43 Pelastin injeksi Imipenem 500 mg + Cilastatin 500 mg inj 1 Vial 311,000 1 311,000 311,000
44 Pibaksin topical ointment Mupirocin oint gen 3 tube 38,000 1 38,000 114,000
45 Prolic 150 mg capsule Klindamisin 150 gen 1 Box 328,000 100 3,280 328,000
46 Prolic 300 mg capsule Klindamisin 300 gen 1 Box 666,500 100 6,665 666,500
47 Pumpitor injeksi Omeprazole 40 mg injeksi 3 Box 139,200 1 139,200 417,600
48 Sanadryl DMP syrup Obat batuk + 60 ml gen 10 Botol 10,750 1 10,750 107,500
49 Sanadryl expectorant syrup Obat batuk 60 ml gen 10 Botol 9,050 1 9,050 90,500
50 San-B Plex drops Multivitamin D gen 10 Botol 16,000 1 16,000 160,000
51 Sanmol drops Paracetamol Drop gen 10 Botol 14,450 1 14,450 144,500
52 Sanmol Forte tab Paracetamol tab 650mg Box 31,000 100 310 0
53 Sanmol infus Paracetamol 1000mg / 100ml 3 Botol 56,600 1 56,600 169,800
54 Sanmol syrup Paracetamol syr gen 125mg 30 Botol 10,750 1 10,750 322,500
55 Sanmol syrup Forte Paracetamol syr gen 250mg Botol 23,700 1 23,700 0
56 Sanmol tablet Paracetamol tab gen Box 26,000 100 260 0
57 Sanprima forte caplet Kotrimoksazole cpt gen 1 Box 184,500 100 1,845 184,500
58 Sanprima syrup Kotrimoksazole syr gen 5 Box 23,600 1 23,600 118,000
59 Sanprima tablet Kotrimoksazole tab gen 1 Box 82,000 100 820 82,000
60 Siclidon 100 mg capsule Doksisiklin 100 gen Box 97,400 20 4,870 0
61 Sinocort oral paste Thiamcinolon pasta Tube 34,350 10 34,350 0
62 Spirasin film-coated tablet Spiramisin tab gen 1 Box 553,500 100 5,535 553,500
63 Taxegram Injeksi Sefotaksim 1 gr inj gen 1 Vial 132,450 1 132,450 132,450
64 Terfacef injeksi Seftriaxon inj gen 2 Vial 195,800 1 195,800 391,600
65 Tremenza syrup Obat flu syr gen 10 Botol 18,500 1 18,500 185,000
66 Tremenza tablet Obat flu tab gen 3 Box 131,500 100 1,315 394,500
67 Trichodazol 500 film-coated tablet Metronidazole 500 tab gen Box 154,000 100 1,540 0
68 Trichodazol infus Metronidazole inf gen Fls 82,750 1 82,750 0
69 Trichodazol plus ovula Metronidazol 500 mg + nistatin 100.000 IU 2 Box 72,900 6 12,150 145,800
70 Urotractin capsule Asam pipemidat cps gen 1 Box 181,500 60 3,025 181,500
71 Valisanbe 5 mg tablet Diazepam 5 mg gen 5 Box 35,000 100 350 175,000
72 Valisanbe Injeksi Diazepam inj gen Box 163,000 10 16,300 0
73 Zidifec injeksi Ceftazidime inj gen 1 Vial 241,800 1 241,800 241,800
74 22,686,150
75
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77
78
79
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81
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83
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f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
I. OBAT ANTI SISTEM GASTROINTESTINAL & HEPATOBILIER

A. ANTASIDA
Sodium Bicarbonat 1 Sodium Bicarbonat Generik Tablet 500 mg G

Mg(OH) + Al(OH)3 1 Antasida Generik Tablet Erela


Antasida Generik Syrup 60 ml Erela

Metilpolisiloksan, MgOH,Al(OH) 1 Polycrol Forte Syrup Nicolas

Mg(OH) + Al(OH)3 + simeticon 1 Acitral Syrup Interbat 50 botol 32,000 1


Acitral Tablet Interbat 5 box 97,500 100
3 Magalat Susp Ferron 25,000 1
Magtral Tablet Otto 70,000 100

1 Sucralfate 1 Molafat Susp 60 cc Molex Ayus


2 Ulsafat Susp 100 cc Combiphar 5 botol 45,980 1
Ulsafat Susp 200 cc Combiphar 5 botol 90,750 1

Rebemipide 1 Rebemipide Tablet 100 mg Novell 3 Box 190,000 100


2 Novepide Tablet 100 mg Novell
3 Sysmuco Tablet 100 mg Fahrenheit

Fucoidan 1 Fucohelix Tablet 100 mg Kalbe Farma


2 Fucoidan 100 Tablet 100 mg Soho

B. ANTI REFLUK DAN ANTI ULSERASI


Ranitidin 1 Ranitidin Generik Injeksi Novell 5 box 31,500 10
Ranitidin Generik Tablet 150 mg Hexpharm 10 box 20,000 100
4 Ranivel sirup 75 mg/5ml Novell 20 Botol 37,000 1
5 Rantin Injeksi 150 mg Kalbe Farma 3 Box 95,000 5
Rantin Tablet Kalbe Farma 10 Box 430,000 100

Omeprazole 1 Omeprazole Generik Capsul 20 mg Hexpharm


Omeprazole Generik Injeksi 40 mg Novel 5 box 50,000 1
2 Pumpitor Injeksi 20 mg Sanbe 3 box 107,500
3 Protop Capsul 20 mg Interbat 3 box 149,000 14

Lansoprazole 1 Lansoprazole Generik Capsul 30 mg Nulab


2 Lancid Capsul 30 mg Kalbe Farma 5 box 275,000 20

Pantoprazol 1 Pantoprazol Generik Capsul 20 mg Dexa Medica 3 box 204,750 30 614,250

73
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
40 mg Dexa Medica 2 box 252,000 30 504,000
Pantoprazol Generik Injeksi 40 mg Novell 3 box 59,000 1 177,000
2 Pranza Injeksi Kalbe Farma 3 vial 136,000 408,000
3 Vomizol Injeksi Dexa Medica 2 vial 150,000 1 300,000
Vomizol tablet 20 mg Dexa Medica 2 box 115,000 230,000

Esomeprazol 1 Nexium Kapsul 20 mg AstraZeneca


Nexium Kapsul 40 mg AstraZeneca 0
Nexium Injeksi 40 mg AstraZeneca 0
0
Misoprostol 1 Gastrul Tablet Fahrenheit 0
2 Invitec Tablet Kalbe Farma 3 box 298,000 30 894,000
3 Noprostol Tablet Vagina Novell 0
C. GIT REGULATOR, ANTI FLATULEN, DAN INFLAMASI 894,000
Sulfasalazine 1 Sulcolon Tablet 500 mg Bernofarm

Budesonide 1 Budenofalk Capsul 3 mg Darya Varia 2 box 1,063,500 50

Lactobasilus Acidophilus 1 Lacto B Sachet Novell 1 box 216,000 40 216,000


3 Liprolac Sachet Kalbe Farma 1 box 180,000 30 180,000
4 Interlac Drop Interbat 1 box 279,000 30 279,000

D. ANTI SPASMODIK
Hyoscine_N_Butylbromide 1 Buscopan Tablet 10 mg Boehringer
Buscopan injeksi Boehringer
2 Buscopan Plus Tablet Boehringer

Hyoscine N B + Paracetamol 1 Scopamin Plus Tablet Otto 2 box 25,000 100


2 Gitas plus injeksi Interbat 2 box 122,500 5

Clinidium Br + Chlordiazepoxid 3 Braxidin Tablet Sanbe Box 100,000 100

Otilonium Bromida 1 Spasmomen Tablet Dexa Medica 2 box 186,000 30

E. ANTI DIARE
Attapulgit Aktif Koloid 1 Diadium Tablet 2 mg Lapi

Loperamide HCl 1 Antidia Tablet 2 mg Bernofarm

Kaolin Pectin 1 Molagit Tablet 600 mg Molex ayus

F. LAKSATIF PENCAHAR
Laktulose 1 Constipen Syrup 120 ml Combiphar 5 botol 77,000 1

74
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

Bisacodyl 1 Dulcolax Tablet Boehringer


Dulcolax Suppos 5 mg Boehringer
Dulcolax Suppos 10 mg Boehringer

Paraffin Gliserin 1 Laxadine Syrup Gelenium

Sorbitol + Na Lauril Sulfat 1 Microlax Suppos 5 mg Pharos


Microlax Suppos 10 mg Pharos
2 Laxoberon Drop Boehringer

G. DIGESTAN
Amilase, Protease, Vit Bpleks 1 Enzyplex Tablet Darya Varia
2 Enzymfort Tablet Kimia Farma

Pankreatin 1 Pankreoflat Tablet Kimia Farma


2 Gasflat Tablet Fahrenheit

H. KOLAGOGUM, KOLELITOLITIK, DAN HEPATOPROTEKTOR

Ursodeoxycholic 2 Urdahex Capsul Kalbe Farma 1 box 260,000 30

Lecithin + Vit Bpleks 1 Lesichol Capsul 300 mg Landson


Lesichol Capsul 600 mg Landson
2 Lesifit Capsul Sandoz

Curcuminoid + Silmarine + Coline 1 Proliver Tablet Simex


2 Biocurliv Tablet Soho
3 Hepamax Kaplet Kalbe Farma

L-ornitin-L-Aspartat 1 Hepa-Merz Sachet Granul Combiphar 1 box 399,300 10


Hepa-Merz Injeksi Combiphar 1 box 575,750 5
1 Forheva Injeksi Kalbe Farma

Neo Mino Phangen C 1 SNMC Injeksi Dexa Medica

Selenium + Bioflavonoids + lipoic acd 1 Livapro SS Capsul Novell


2 Proliva Kaplet Gracia box 140,000 20

Palecatechu + Curcumin 1 Rejuvit Capsul Nutrindo

I. PREPARAT ANOREKTAL / ANTI HEMOROID


Anti hemoroid 1 Anti hemoroid Generik Suppos kimia farma 10 box 30,000 10

75
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

Fluocortolon + Lidocain 1 Ultraproct N Suppos Schering


Ultraproct N Salep Schering

Lithospermi+Benzokain+Difenhidram 1 Borraginol - N Suppos Takeda

Sda + Prednison 1 Borraginol - S Suppos G

Hydrosmin 1 Venosmil Gel 60 gr Kalbe Farma 1 tube 135,000 1

Citrus Bioflavonoid+diosmin 1 Ardium HD Tablet 500 mg Servier


2 Ciflon Kaplet Lapi

J. ANTIEMETIK
Domperidone 1 Domperidone Generik Tablet 10 mg Nulab
Domperidone Generik Syrup Hexpharm
2 Vometa Drop Dexa Medica 39,500 1
3 Vosedon Syrup Sanbe Botol 27,000 1
Vosedon Tablet Sanbe Box 215,500 100
4 Monell syrup drp Novell Botol 42,500

Metoclorpramide 1 Metoclorpramide Generik Tablet 10 mg Kimia Farma


Metoclorpramide Generik Injeksi 10mg/2ml G
2 Piralen Syrup 5 mg Otto 10 Botol 9,000 1
Piralen Tablet 10 mg Otto 2 Box 60,000 100
Piralen Injeksi 10 mg/2 ml Otto 1 box 40,000 5

Dimenhidrinate 1 Dimenhidrinate Generik Tablet Kimia Farma 2 box 12,980 100

Piradhiazine+Chloropheophylinate+Vit. B6 1 Anvomer B6 Tablet Dexa Medica 2 box 144,000 60

Ondansentron 1 Ondansentron Generik Injeksi 4 mg Dexa box 26,250 5


Ondansentron Generik Injeksi 8 mg Dexa box 42,000 5
Ondansentron Generik Tablet 4 mg Nulab box
Ondansentron Generik Tablet 8 mg Nulab box
2 Dansefion Injeksi 4 mg Infion box 115,000 5
3 Invomit Tablet 4 mg Interbat 5 box 280,800 18
Invomit Tablet 8 mg Interbat 5 box 425,250 18
4 Ceteron Injeksi 8 mg Combiphar box 187,000 5
K. OBAT GASTROINTESTINAL LAIN
Lyophilized cyclic - somatostatin 1 Somatostatin Lyomark Injeksi 250 mcg/3 mg Combiphar 1 box 814,000 10
2 Somatostatin Eumedica Injeksi 250 mcg/3 mg Dexa Medica

76
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
II. SISTEM KARDIOVASKULER DAN HEMATOPOITIK

A. OBAT JANTUNG
Digoxin 1 Digoxin Generik Tablet 0.25 mg Indofarma
2 Fargoxin Tablet 0.25 mg Fahrenheit
Fargoxin Injeksi 0.5 mg/2 ml Fahrenheit

Dobutamin HCl 1 Dobutamin injeksi novel 3 box 37,100 1


1 Dobuject Injeksi 250 mg Dexa Medica 1 box 675,000 5

Dopamin HCl 1 Dopamin Giulini Injeksi Kimia Farma

Amiodaron HCl 1 Kendaron Injeksi 150 mg / 3ml Darya Varia 2 box 135,000
2 Tiaryt Tablet 200 mg Fahrenheit

Profapenon HCl 1 Rhytmonorm Tablet 150 mg Abbott

B. OBAT ANTI ANGINA


Isosorbidedinitrate 1 Isosorbidedinitrate Generik Tablet 10 mg kimia farma
2 Cedocard Tablet 5 mg Darya Varia 2 Box 62,000 60
Cedocard Tablet 10 mg Darya Varia 2 Box 92,000 60
Cedocard Injeksi 10 mg / 10 ml Darya Varia 1 Box 78,750 10

Diltiazem 1 Diltiazem Generik Tablet 30 mg Dexa 5 box 14,474 100


2 Herbesser Injeksi Tanabe

3 Herbesser CD Tablet 100 mg Tanabe


Herbesser CD Tablet 200 mg Tanabe

4 Farmabes Injeksi 5 mg/ml, 5 ml Fahrenheit


Farmabes Tablet Fahrenheit
5 Cordila SR Tablet 180 mg Dexa Medica 2 box 150,000 30

Amlodipine besylate 1 Amlodipine Generik Tablet 5 mg Ethica 20 box 43,636 50


Amlodipine Generik Tablet 10 mg Ethica 20 box 76,945 50
2 Intervask Tablet 5 mg Interbat 5 box 201,000 30
Intervask Tablet 10 mg Interbat 5 box 348,000 30
3 Theravask Tablet 5 mg Darya Varia 120,450 30
Theravask Tablet 10 mg Darya Varia 175,450 30

C. ACE - INHIBITOR
Captopril 1 Captopril Generik Tablet 12,5 mg Dexa
Captopril Generik Tablet 25 mg Dexa

77
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Captopril Generik Tablet 50 mg Dexa
2 Captensin Tablet 12,5. mg Kalbe Farma
Captensin Tablet 25 mg Kalbe Farma
Captensin Tablet 50 mg Kalbe Farma

Ramipril 1 Ramipril generik Tablet 5 mg Dexa 5 box 55,450 100


2 Hyperil 5 mg Tablet 5 mg Ferron 2 box 450,000 60

Lisinopril 1 Interpril Tablet 5 mg Interbat 5 box 93,600 30


Interpril Tablet 10 mg Interbat 5 box 139,500 30

Imidapril HCl 1 Tanapres Tablet 10 mg Tanabe

Enalaprilmaleate 1 Renacardon Tablet 5 mg Fahrenheit


Renacardon Tablet 10 mg Fahrenheit

Perindopril 1 Bioprexum Tablet 5 mg Servier

D. PENYEKAT BETA
Bisoprolol 1 Bisoprolol Generik Tablet 5 mg Dexa
2 Concor Tablet 5 mg Merck
3 B Beta Tablet 5 mg Ferron 2 box 178,000 30
4 Bisovell Tablet 5 mg Novell

Propanolol 1 Propanolol Generik Tablet 10 mg Dexa Medica


Propanolol Generik Tablet 20 mg Dexa Medica
2 Farmadral Tablet 10 mg Fahrenheit

Atenolol 1 Farnormin Tablet 50 mg Fahrenheit

Nebivolol 1 Nebilet Tablet 5 mg Dexa Medica

E. ANTAGONIS KALSIUM
Nifedipin 1 Nifedipin Generik Tablet 10 mg Dexa
2 Adalat Oros 30 mg Bayer

Verapamil 1 Isoptin SR Tablet 240 mg Abbott

Nicardipine HCl 1 Nicardipine Injeksi 10 mg / 10 ml Novel 1 box 800,000 10


2 Perdipine injeksi Injeksi 10 mg / 10 ml Astellas
3 Carsive Injeksi 10 mg / 10 ml Landson

78
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
F. ANTAGONIS ANGIOTENSIN II
Candesartan cilexetil 1 Candesartan Generik Tablet 8mg Dexa Medica
Candesartan Generik Tablet 16 mg Dexa Medica
2 Candefion Tablet 8mg Infion box 150,000 30
Candefion Tablet 16 mg Infion box 225,000 30

Losartan K 1 Losartan Generik Tablet 50 mg Hexpharm


2 Insaar Tablet 50 mg Interbat 5 box 346,500 30
3 Lifezar Tablet 50 mg Darya Varia box 273,000
Lifezar Tablet 100 mg Darya Varia box 193,500

Irbesartan 1 Iretensa Tablet 150 mg Fahrenheit


2 Irvask Tablet 150 mg Kalbe Farma 3 box 280,000 30
300 mg Kalbe Farma 3 box 370,000 30
Olmesartan 1 Olmetec Tablet Pfizer

Telmisartan 1 Telmisartan Tablet 40 mg Dexa Medica 2 box 126,000 30


2 Micardis Tablet 40 mg Boehringer

H. OBAT HIPERTENSI KOMBINASI


Amlodipine besylate+valsartan 1 Exforge Tablet 5/80 mg Novartis
Exforge Tablet 5/160 mg Novartis

Amlodipine besylate + Atorvastatin Ca 1 Caduet Tablet Pfizer

Perindopril + Amlodipine 1 Coveram Tablet 5/5 mg Servier


Coveram Tablet 5/10 mg Servier

Valsartan + HCT 1 Co-Diovan Tablet 80/12.5 mg Novartis

Telmisartan + Amlodipine 1 Twynsta Tablet 40/5 mg Boehringer

I. ANTI HIPERTENSI GOLONGN LAIN


Clonidine 1 Clonidine Generik Tablet 75/150 mcg Kimia Farma 10 box 18,636 100
2 Catapres Tablet 75/150 mcg Boehringer
Catapres injeksi 150 mg Boehringer

Methyldopa 1 Dopamet Tablet 250 mg Actavis

J. DIURETIK
Furosemid 1 Furosemid Generik Tablet 40 mg Kimia Farma 10 box 22,200 100
2 Farsix Tablet 40 mg Fahrenheit

79
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Farsix Injeksi 20 mg / ml Fahrenheit
3 Lasix Tablet 40 mg Aventis
Lasix Injeksi 20 mg / ml Aventis

Hydrochlorthiazide 1 HCT Generik Tablet 25 mg Kimia Farma 10 box 11,636 100

Spironolactone 1 Spironolactone Generik Tablet 100 mg Dexa Medica 10 box 100,700 100
2 Carpiaton Tablet 100 mg Fahrenheit

Manitol 1

K. VASODILATOR PERIFER DAN AKTIFATOR SEREBRAL


Citicholine 1 Citicholine Generik Tablet 500 mg Hexpharm
Citicholine Generik Injeksi 250 mg Hexpharm 3 box 54,545 5
Citicholine Generik Injeksi 500 mg Hexpharm 2 box 109,091 5
2 Braint act Tablet 500 mg Kalbe Farma 2 box 366,000 30
Braint act Injeksi 500 mg Kalbe Farma 1 box 333,000 5
3 Incelin Tablet 500 mg Interbat 5 box 438,000 30
Incelin Injeksi 250 mg Interbat 1 box 197,500 5
4 Cition Tablet 1000 mg Infion box 450,000 30
Cition Tablet 500 mg Infion box 315,000 30
Cition Injeksi 250mg/2ml Infion box 125,000 5

Nimodipin 1 Nimodipin infus 0.2 mg/ml Novel 2 botol 175,000

fosfatidil serin 1 Memoran Capsul 100 mg Soho

Ginkgo biloba 1 Tanakan Tablet Combiphar 1 box 175,692 30

L. VASOKONSTRUKTOR
Nor Epinephrin 1 Raivas Injeksi 4 mg Dexa Medica 1 box 450,000 5
2 Vascon Injeksi 4 mg Fahrenheit
3 Nor epineprin generik Injeksi 4 mg Berno

M. OBAT DISLIPIDEMI
Simvastatin 1 Simvastatin Generik Tablet 10mg Berno
Simvastatin Generik Tablet 20mg Berno
2 Kolefion Tablet 20 mg Mersi

Ca-Rosuvastatin 1 Crestor Tablet Astra

Fenofibrate 1 Lipanthyl Tablet 200mg Combiphar

80
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
2 Fibramed Tablet 300 mg Promed
3 Yosenob Tablet 300 mg Nufarindo

Ca-Atorvastatin 1 Lipitor Tablet 10mg Pfizer


Lipitor Tablet 20mg Pfizer
2 Atorsan Tablet 10mg Sandoz
Atorsan Tablet 20mg Sandoz

Atorvastatin 1 Atorvastatin Generik Tablet 10 mg Dexa Medica


2 Stator Tablet 20mg Dexa Medica 2 box 480,000 30
3 Truvas Tablet 10mg Kalbe Farma 2 box 405,000 30

Gemfibrozil 1 Gemfibrozil Generik Tablet 300 mg G


2 Lipitrob Tablet 600 mg Tropicamas

Simvastatin + Ezetimibe 1 Vytorin Tablet 10/10 mg MSD

N. HEMOSTATIK
Asam tranexamat 1 Kalnex Tablet 250 mg Kalbe Farma 2 box 160,000 100
Kalnex Tablet 500 mg Kalbe Farma 2 box 300,000 100
Kalnex Injeksi 250 mg Kalbe Farma 5 box 90,000 10
2 Intermic Injeksi 250 mg Interbat 1 box 94,500 5
3 Asam Tranxamat generik Tablet 250 mg Bernofarm
Asam Tranxamat generik Tablet 500 mg Bernofarm
Asam Tranxamat generik injeksi 250 mg novell 3 box 23,000 5
Asam Tranxamat generik injeksi 500 mg novell 5 box 63,000 10

Carbazochrome sodium sulfonat 1 Adona AC Injeksi 25 mg Tanabe


Carbazochrome sodium sulfonat Adona AC Injeksi 50 mg Tanabe
Carbazochrome sodium sulfonat Adona AC Tablet 10 mg Tanabe
Carbazochrome sodium sulfonat 2 Crome Injeksi 50 mg Ferron 1 box 200,000 10
Crome Tablet 10 mg Ferron 1 box 200,000 100

Vitamin K 1 Menadione Tablet 10 mg Kimia Farma 5 box 19,636 100


2 Neo K Injeksi Combiphar 5 box 68,200 5
3 Phyfion injeksi 2 mg/ml Infion 3 box 50,000 5

O. ANTI KOAGULAN, ANTI PLATELET DAN FIBRINOLITIK


As. Asetilsalisilat 1 Aspilet Tablet 80 mg UAP
2 Ascardia Tablet 80mg Pharos
Ascardia Tablet 160mg Pharos
3 Thrombo Aspilet Tablet Medifarma

81
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

As. Asetilsalisilat + Glycine 1 Proxime Tablet Sanbe

Ticlopidin HCl 1 Cartrilet Tablet 250 mg Fahrenheit

Cilostazol 1 Pletaal Tablet 100mg Otsuka


2 Citaz Tablet 50mg Dankos

Streptokinase 1 Streptase Injeksi 1.500.000 IU Dexa Medica

Parnaparin 1 Fluxum Injeksi 0,4 cc Fahrenheit


Fluxum Injeksi 0,6 cc Fahrenheit

Enoxaparin Na 1 Lovenox Injeksi 0.2, cc Sanofi


Lovenox Injeksi 0.4, cc Sanofi
Lovenox Injeksi 0.6 cc Sanofi

Fondaparinux Na 1 Arixtra Injeksi 2.5 mg Glaxo

Clopidogrel 1 Clopidogrel Generik Tablet 75 mg Dexa


2 Pladogrel Tablet 75 mg Fahrenheit
3 Clogin Tablet 75 mg Interbat 1 box 467,600 28

Dabigatran etexillate 1 Pradaxa Capsul 75 mg Boehringer


Pradaxa Capsul 150 mg Boehringer

Fibrinolisin + Profibrinolisin aktifator 1 Plasmin Capsul 250 mg Landson

Nattokinase + Q10 1 Natto-10 Tablet Lapi

Nattokinase+Bromelain+Papain+Bioflavonoid 1 Fibrinase Kapsul Escolab

Warfarin Na 1 Simarc-2 Tablet 2 mg Fahrenheit

P. OBAT PLEBITIS/VARISES
1 Thrombophob Gel 20 gr Tunggal I.A

Q. HEMATOPOIETIK
-

III. SISTEM PERNAPASAN

82
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
A.OBAT ANTI ASMA DAN PPOK
Theophylline 1 Bronchophyllin Syrup 100 cc 150 mg/15 ml Darya Varia 5 botol 16,500 1

Theophylline Anhidrous 1 Euphyllin R Tablet 250 mg Pharos


2 Euphyllin Retard Mite Tablet 125 mg Pharos

Terbutalin Sulfat 1 For Asma Tablet 2.5 mg Guardian


Terbutalin Sulfat 2 Theobron Syrup Interbat 10 botol 37,400 1
Theobron Caps Interbat 2 box 205,000 100

Salbutamol 1 Salbutamol Generik Tablet 2 mg Kimia Farma 5 box 7,639 100


Salbutamol Generik Tablet 4 mg Kimia Farma 5 box 9,130 100
Salbutamol Generik Syrup Indo Farma
3 Astharol Syrup Sanbe 10 Botol 13,950 1

Efedrin HCl 1 Efedrin HCl Generik Tablet 25 mg Kimia Farma 5 box 14,327 100
Injeksi 50 mg/ml G

Procaterol HCl 1 Ataroc Syrup 25 mcg Novell


2 Meptin Tablet 50 mcg Otsuka
3 Meptin swing heler Spray 10 mcg/dosis Otsuka

Budesonide+Formoterol 1 Symbicort Turbo Heler Inhaler 60 dosi 80/4.5 AstraZenica


Symbicort Turbo Heler Inhaler 60 dosi 160/4.5 AstraZenica

Salmeterol+Fluticasone 1 Seretide Spray Inhaler 125 mcg Glaxo


1 Seretide Discus Inhaler 500 mcg Glaxo

Salbutamol 1 Ventolin Inhaler Glaxo


Nebuls
Ipatropium+Salbutamol 1 Combivent Nebuls 0.5mg/2.5mg Boehringer
2 Farbivent Nebuls 0.5mg/2.5mg Fahrenheit

Flucitasone Propionat 1 Flixotide Nebuls Glaxo

Budesonide 1 Pulmicort Nebulizer AstraZenica

B. OBAT BATUK DAN PILEK


Ambroxol 1 Ambroxol Generik Tablet 30 mg Essa Indo
Ambroxol Generik Syrup 60 ml Kimia Farma 30 botol 3,446 1
2 Molapect Syrup 15mg/5ml Molex ayus
Molapect Tablet 30 mg Molex ayus
3 Interpect Tablet 30 mg Interbat 1 box 130,000 100

83
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Interpect Eliksir Interbat 10 botol 40,950 1
4 Mucos Drop 20 ml Meprofarm 5 16,000 1
Mucos Syrup 60 mg Meprofarm 5 33,500 1

Bromhexin HCl 1 Bisolvon Tablet 4 mg Boehringer


Bisolvon Tablet 8 mg Boehringer
Bisolvon Injeksi 2mg/ml Boehringer
2 Mucohexin Tablet 8 mg Sanbe Botol 15,200 1
Mucohexin Eliksir 120 ml Sanbe Box 46,000 100

Glyceril Guaiacolat 1 Glyceril Guaiacolat Generik Tablet Kimia Farma 5 box 9,818 100
2 OBH Generik Syrup Molex ayus

N-Acetylcysteine 1 N-Acetylcysteine Tablet


1 Fluimucil Eff Tablet 600 mg Zambon
1 Simucil Capsul 200 mg Mersifarma

Erdostein 1 Edotin Capsul 300 mg Ferron botol 75,000 20


2 Vestein Syrup 175 mg/5 ml Kalbe Farma botol 35,000 1
Vestein Capsul 300 mg Kalbe Farma box 80,000 20
3 Vectrin Syrup 175 mg/5 ml Dexa Medica botol 36,000
4 Mucotein Capsul 300 mg Combiphar 1 box 102,850 20
5 Mucotein DS Syrup 175mg/5 ml Combiphar 5 botol 33,880 1

Obat Batuk Kombinasi 1 Comtusi Syrup 60 ml Combiphar 20 botol 37,400 1


2 Sanadryl DMP Syrup 60 ml Sanbe Botol 10,750 1
Sanadryl expectorant Syrup 60 ml Sanbe Botol 9,050 1
3 Dextral Tablet Molex Ayus Box
Dextral Syrup Molex Ayus Botol

Obat Batuk Kombinasi+Paracetamol 1 Alpara Tablet Molex Ayus


Alpara Syrup Molex Ayus

Loratadin+Pseudoepedrin 1 Aldisa SR Capsul Sanbe 2 Box 231,000 50


2 Rhinos SR Capsul Dexa Medica 2 box 225,000 50
3 Rhinos Neo Drop Dexa Medica 5 39,000 1
4 Rhinos Junior Syrup Dexa Medica 5 30,000

Tripolidin+Pseudoepedrin+Dextro 1 Lapifed DM Syrup Lapi

Tripolidin+Pseudoepedrin 1 Tremenza Tablet Sanbe Box 131,500 100


Tremenza Syrup Sanbe Botol 18,500 1
Tripolidin+Pseudoepedrin 2 Trifed Tablet Interbat 2 box 112,500 100

84
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Trifed Syrup Interbat 10 botol 27,300 1

Pseudoepedrin 1 Alco Drop Interbat 20 botol 66,750 1

Pseudoepedrin + DMP 1 Alco syrup Interbat 20 botol 48,000 1

Tervenadine+Pseudoepedrin 1 Rhinofed Tablet Dexa Medica 2 box 77,000 50

Fexofenadine+Pseudoepedrin 120 1 Fexofed Tablet Kalbe Farma 2 box 117,000 30

Troxerutin+Zn Gluconat 1 Coldizo Tablet isap Soho

Codein 1 Codein Tablet 20 mg Kimia Farma 3 box 12,100 100


2 Codipront Tablet 30 mg Kimia Farma
Codipront Syrup Kimia Farma
Codein+GG 1 Codipront Cum Expect. Tablet Kimia Farma
Codipront Cum Expect. Syrup Kimia Farma
Noscapine 1 Levopront Syrup 60 ml Combipharm 2 botol 66,000 1

IV. SISTEM SARAF PUSAT


A. ANSIOLITIK
Diazepam 1 Diazepam generik Tablet 5mg Indro Farma
Diazepam generik Tablet 10mg Indo Farma
2 Valisanbe Tablet 5 mg Sanbe Box 35,000 100
3 Stesolid Injeksi 10 mg Actavis
Stesolid Suppos 5mg Actavis
Stesolid Suppos 10mg Actavis

Alprazolam 1 Alprazolam Generik Tablet 0.5mg Dexa


Alprazolam Generik Tablet 1mg Dexa
2 Feprax Tablet 0,5mg Ferron 3 box 52,000 30
Feprax Tablet 1 mg Ferron 2 box 79,000 30
4 Zypraz Tablet 0.5 mg Kalbe Farma 3 box 125,000 50

Clobazam 1 Clobazam Generik Tablet 10mg G

Lorazepam 1 Ativan Tablet 1mg Sunti S


Ativan Tablet 2mg Sunti S

Bromazepam 1 Lexotan Tablet 1.5mg Roche


Lexotan Tablet 3mg Roche

D. HIPNOTIK SEDATIV

85
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Zolpidem Tartrat 1 Zolmia Tablet 10 mg Fahrenheit

Midazolam 1 Dormicum Injeksi 5 mg/5 ml Roche

E. ANTI DEPRESAN
Sertralin 1 Deptral Tablet 50 mg Meprofarm
2 Serlof Tablet 50 mg Kalbe Farma 1 box 420,000 30
3 Nudep Capsul 50 mg Guardian

Fluoxetine HCl 1 Kalxetin Capsul 10 mg Kalbe Farma 2 box 110,000 30


Kalxetin Capsul 20 mg Kalbe Farma 2 box 170,000 30

Maprotiline HCl 1 Tilsan Tablet 25 mg Otto

Tianeptine 1 Stablon Tablet 12.5 mg Servier

Clomipramine 1 Anafranil Tablet 25 mg Novartis

Neuravena 1 Nurest Capsul 350 mg Nulab

G. ANTI KEJANG
Phenobarbital 1 Phenobarbital Generik Tablet 30 mg G
2 Phental Injeksi Combiphar 2 box 46,200 5
Phenobarbital+Pipenzolate+Ethanol 1 Piptal Drop Nicholas

Asam Valproic 1 Depakene Syrup 250 mg/5 ml Abbot

Na-Divalproic 1 Depakote ER Tablet 500 mg Abbot


2 Valeptik Syrup 250 mg Otto 3 botol 75,000 1

Na-Phenitoin 1 Phenitoin Generik Capsul 100 mg G


Phenitoin Generik Injeksi 100 mg/2 ml Novell 2 box 325,000 10
2 Dilantin Tablet 100mg Pfizer
3 Kutoin Injeksi 100 mg/2 ml Mersifarma

Carbamazepin 1 Carbamazepin Generik Tablet 200 mg G


2 Tegretol Tablet 100 mg Novartis
Tegretol Tablet CR 200 mg Novartis

Pregabalin 1 Lyrica Tablet 75mg Pfizer


2 Provelyn Tablet 75 mg Kalbe Farma 1 box 138,320 14
Provelyn Tablet 150 mg Kalbe Farma 1 box 190,000 14

86
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Gabapentin 1 Neurontin Capsul 300mg Pfizer
2 Ganin Tablet 300mg Ferron

H. OBAT SSP GOL. LAIN


Metilphenidate 1 Ritalin Tablet 10 mg Novartis

I. OBAT PENYAKIT NERODEGENARATIF


Donepezil HCl 1 Aricept Tablet 5 mg Eisai

J. OBAT ANTI PARKINSON


Triheksipenidil 1 THP Generik Tablet 2 mg
2 Heximer Tablet 2 mg Mersifarma

K. OBAT ANTIVERTIGO
Betahistine mesylat 1 Mertigo Tablet 8 mg Dexa Medica
2 Merislon Tablet 12 mg EISAI

Cinnarizine 1 Stugeron Tablet 25 mg Jannson

L. ANALGESIC (OPIAT)
Tramadol 1 Tramadol Generik Capsul 50 mg Kimia Farma 5 box 19,794 50
Injeksi 50 mg/ml Novell 5 box 29,100 5
2 Tradyl tablet 50 mg Interbat 2 box 192,500 50
Injeksi 50 mg/ml Interbat 10 box 97,000 5
Tramadol + Parasetamol 1 Analtram Tablet Lapi

M. ANALGESIC (NON OPIAT)+ANTI PIRETIK


Paracetamol 1 Paracetamol Generik Tablet 500 mg G
Paracetamol Generik Syrup 120 mg/ 5 ml, 60 ml G
Paracetamol Generik Drop 100 mg/ml, 15 ml G
Paracetamol Generik Infus 1g Darya Varia 10 Botol 20,000 1
2 Dumin Supp 125 mg Dexa Medica
Dumin Supp 250 mg Dexa Medica
4 Sanmol Tablet 500 mg Sanbe Box 26,000 100
Sanmol Syrup 120 mg/5 ml, 60 ml Sanbe Botol 10,750 1
Sanmol Drop Sanbe Botol 14,450 1
Sanmol Infus 1000 mg Sanbe Botol 56,600 1
5 Pamol Syrup 120 mg/5 ml, 60 ml Interbat 20 botol 23,000 1
Pamol Drop 125 mg, 250 mg Interbat 20 botol 40,000 1
Pamol Supp Interbat 1 botol 132,000 12
6 Eterfix Syrup 500 mg/50 ml Novel; botol 45,000 1

Ibuprofen 1 Iprox Syrup 101 mg/5ml, 60 ml Novel Botol 45,000 1

87
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
2 Bufect Forte Syrup 100 mg/5ml, 60 ml Sanbe Botol 19,000 1
3 Bufect Syrup Sanbe Botol 13,450 1
4 Proris Suspensi 200 mg/ 5 ml Pharos
Proris Supp 125 mg Pharos

N. OBAT ANTI INFLAMASI NON STEROID


Ibuprofen 1 Ibuprofen Generik Tablet 400 mg Great

Ibuprofen Arginin 1 Spedifen Tablet 400 mg Zambon

Asam Mefenamat 1 Asam mefenamat Generik Tablet 500 mg Hexpharm


2 Mefinal Tablet 250 mg Sanbe Box 56,500 100
Mefinal Tablet 500 mg Sanbe Box 123,000 100
3 Mefinter Tablet 250 mg, 500 mg Interbat 5 box 185,000 100
4 Pondex Tablet 250 mg, 500 mg Dexa Medica

Ketorolac 1 Ketorolac Generik Injeksi 10 mg Novell 3 box 40,909 6


30 mg Hexapharm 5 box 27,273 6
Ketorolac Trometamin 1 Trolac Kaplet 10 mg Bernofarm
Torasic Injeksi 30 mg/ml Kalbe Farma box 200,000 6
2 Torasic Tablet 10 mg Kalbe Farma 3 box 100,000 20
3 Etofion Injeksi 30 mg/ml Infion box 150,000 5
Ketrobat injeksi 10 mg interbat 2 box 110,000 5

Natrium diklofenac 1 Natrium diklofenac Generik Tablet 25mg, 50 mg Bernofar


2 Dolofenac Na Tablet Merck
3 Voltaren Tablet SR 75 mg Novartis
Voltaren Tablet Retard 100 mg Novartis
Voltaren Gel 1% 20 gr Novartis

Natrium diklofenac + Vit. B Plek 1 Neurofenac Plus Tablet 50 mg Merck

Kalium diklofenac 1 Kalium diklofenak tablet 50 mg Nulab


Kalium diklofenak tablet 25 mg Nulab
1 Cataflam D Tablet 50 mg Novartis
2 Cataflam Drop Drop Novartis
3 Cataflam Fast Sachet 50 mg Novartis
4 X-Flam Tablet 50 mg Combiphar 3 box 60,060 30
5 Diflam tablet 50 mg Interbat 5 box 167,500 50

Piroxicam 1 Piroxicam Generik Capsul 10 mg Indo Farma


Piroxicam Generik Capsul 20 mg Indo Farma
2 Feldene Tablet 10 mg Pfizer

88
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Feldene Tablet 20 mg Pfizer
Feldene Gel

Meloxicam 1 Meloxicam Generik Tablet 7,5mg Nulab


Meloxicam Generik Tablet 15mg Nulab
2 Artrilox Tablet 15 mg Combiphar 3 box 153,670 20
3 Mecox Tablet 15 mg Ferron 170,000 20
4 Meloxin Injeksi 10 mg /ml Interbat 3 box 140,925 5

Celecoxib 1 Celebrex Capsul 200mg Pfizer

Etoricoxib 1 Arcoxia Kaplet 60 mg MSD


Arcoxia Kaplet 90 mg MSD
Arcoxia Kaplet 120 mg MSD

Ketoprofen 1 Kaltrofen Suppos 100 mg Kalbe Farma 2 box 125,000 10


Kaltrofen Injeksi 100 mg / 2ml Kalbe Farma 2 box 125,000 5
2 Pronalges Tablet 50 mg Dexa Medica box 125,000 50
Pronalges Tablet 100 mg Dexa Medica box 225,000 50
Pronalges Supp 100 mg Dexa Medica box
Pronalges Injeksi 100 mg / 2ml Dexa Medica
3 Pronalges CR Tablet 200 mg Dexa Medica box 480,000 60

Dexketoprofen 1 Dexketoprofen Tablet


injeksi 25mg/mL Novell 5 Box 115,000 5
1 Ketesse Tablet Ferron 2 Box 400,000 50
Ketesse Injeksi Ferron 3 Box 235,000 5

Nabumetone 1 Goflex Tablet 500 mg Guardian

Metamizol Sodium Na 1 Norages Injeksi 500 mg/ml Meprofarm

Metampiron 1 Antalgin Generik/Lexagin Tablet 500 mg Molex Ayus

Metampiron +Chlordiazepoxid+Vit. B 1 Neurogen Tablet 500 mg Bernofarm


2 Neurodial Tablet Kimia Farma
3 Proneuron Tablet Meprofarm

Metampiron+Kafein+Vit.B 1 Neuralgin RX Tablet 500 mg Kalbe Farma

Tinoridine HCl 1 Nonflamin Capsul Takeda

Codein 30mg+Paracetamol 500mg 1 Coditam Tablet Kimia Farma

89
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

Paracetamol+Tramadol 1 Tramifen Tablet Otto


2 Ultracet Tablet Janssen
3 Analtram tablet Janssen
O. ANTI MIGRAIN
1 Degrium Tablet 5 mg Dexa Medica
Flunarizine 2 Frego Tablet 5 mg Kalbe Farma 1 box 370,000 50
Frego Tablet 10 mg Kalbe Farma 1 box 288,750 50

P. NOOTROPIK DAN NEUROTONIK


Piracetam 1 Piracetam Generik Capsul 800 mg Novell
Piracetam Generik Injeksi 1 gr Novell 1 box 72,000 12
Piracetam Generik Injeksi 3 gr Novell 2 box 75,000 4
Piracetam Generik Infus 12 gr/60 ml Novell 2 botol 70,000 1
3 Neurotam Capsul 800 mg Kalbe Farma 2 box 190,000 50
Neurotam Injeksi 1 gr/5 ml Kalbe Farma 1 box 160,000 10
Fepiram Infus 12gr/60 m Ferron box 165,000 1

Pyritinol HCl Monohydrate 1 Encephabol Tablet 100 mg Merck


Encephabol Syrup 100 ml Merck

Sulbutiamine 1 Arcalion Tablet 200 mg Servier

Mecobalamin 1 Mecobalamin Generik Tablet 500 mcg Nulab


Injeksi 500 mcg Novell 2 box 80,000 10
2 Labipal Capsul 500 mcg Lapi
Labipal Injeksi 500 mcg Lapi
3 Megabal Capsul 500 mcg sanbe

V. SISTEM MUSKULOSKELETAL

A. DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARD)


-
B. OBAT HIPERURISEMIA & GOUT
Allopurinol 1 Allopurinol Generik Tablet 100 mg Hexapharm
Allopurinol Generik Tablet 300 mg Hexapharm
2 Zyloric Tablet 100mg Glaxo
3 Benoxuric Tablet 300mg Bernofarm
5 Urica Tablet 100mg Sandoz
Urica Tablet 300mg Sandoz

Colchicine 1 Recolfar Tablet 0.5 mg Fahreinheit

90
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
C. RELAKSAN OTOT
Eperisone HCl 1 Myonal Tablet 50 mg Eisai
2 Myori Tablet Tempo

Tizanidine HCl 1 Myores Tablet 2 mg Meprofarm

D. ENZIM ANTIIMFLAMASI
Serrotiopeptidase 1 Flavin Tablet Landson

Serapeptase 2 Dansera Tablet Otto

E. OBAT LAIN YANG BEKERJA PADA SISTEM MUSKULOSKELETAL


Glucosamine HCl+Condroitine 1 GCM Kaplet Simex
2 GCM Forte Kaplet Simex

Glucosamine HCl+Condroitine+OM3 1 Zotic Kaplet 30 mg Novell

Glucosamine Sulfat 1 Mediflex Krim Kalbe Farma

VI. HORMON

A. ANDROGEN & PREPARAT SINTETIKNYA


Testosteron Undekanoat 1 Andriol Kapsul 40 mg Schering

Danazol 1 Azol Tablet 200 mg Merck

B. ESTEROGEN & PROGESTERON SERTA PREPARAT SINTETIKNYA


Estradiol valerate+Nogestrel 1 Cyclo-Progynova Tablet Bayer

Estrogen Konjugasi 1 Estero Tablet 0.625 mg

Norethisteron 1 Norelut Tablet 5mg Dexa Medica


2 Regumen Tablet 5mg Sanbe

Medroxyprogesterone acetat 1 Provera Tablet 10mg Pfizer

Nomegestrol Acetat 1 Luthenyl Kaplet Merck

Ethinylestradiol 1 Lynoral Tablet Organon

C. KOMBINASI HORMON-HORMON KELAMIN


-

91
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
D. HORMON KORTIKOSTEROID
Sama dengan Anti Alergi

E. HORMON-HORMON TROPIK & PREPARAT SINTETIKNYA


Leuprolide Acetate 1 Endroline Injeksi 3.75 mg Kalbe Farma

Clomiphene Citrat 1 Blesifen Tablet 50mg Sanbe


3 Profertil Tablet 50mg Darya Varia
4 Provula Tablet 50mg Dexa Medica

F. PREPARAT ANABOLIK
-
G. OBAT LAIN YANG MEMPENGARUHI REGULASI HORMONAL
-

VII. KONTRASEPSI

A. KONTRASEPSI ORAL
Desogestrel 1 Cerazette Tablet 75 mcg Schering

Cyproterone acetate+Ethinylestradiol 1 Diane Tablet Schering

Lynestrenol 1 Exluton Limas Tablet 0,5 mg Schering

Levonorgestrel 1 Microlut Tablet 30 mcg Bayer

Levonorgestrel+Ethinylestradiol 1 Mycroginon Tablet Bayer


2 Triquilar ED Tablet Schering

Ethynilistradiol+Drospirenone 1 Yasmin Tablet Bayer


2 Yaz Tablet Bayer

Estradiol+Drospirenone 1 Angeliq Tablet Bayer

1 Engelic Tablet Schering

B. KONTRASEPSI SUNTIK
1 Cyclofem Injeksi Schering

C. KONTRASEPSI LAIN
1 Andalan Tablet Bayer

92
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
VIII. ANTI INFEKSI (SISTEMIK)
A. AMINOGLIKOSIDA
Gentamycin 1 Gentamycin Generik Injeksi G
2 Sagestam Injeksi Sanbe
3 Gentalex cream Cream Molex Ayus

Kanamycin Sulfat 1 Kanamycin Meiji Injeksi 1 gr Meiji


Kanamycin Meiji Injeksi 2gr Meiji

Amikasin Sulfat 1 Amikasin Sulfat Generik Injeksi 250 mg/2 ml Dexa medica
2 Mikasin Injeksi 500mg/2ml Kalbe Farma 3 box 165,000 1
4 Glybotic Injeksi 250 mg Sanbe Box 365,800 4
Glybotic Injeksi 500 mg Sanbe Box 633,800 4

Phospomycin 1 Phosmycin Injeksi 500 mg Meiji

Streptomycin Sulphat 1 Streptomycin Sulphat Injeksi 1 gr Meiji

B. SEFALOSPORIN
GENERASI I
Sefadroxil 1 Cefadroxil Generik Capsul 500mg Bernofarm
Cefadroxil Generik Syrup Bernofarm
2 Cefat Syrup 125 mg/ 5 ml Sanbe Botol 39,700 1
Cefat Capsul 500 mg Sanbe Box 965,000 100
3 Cefat F Syrup 250 mg/ 5 ml Sanbe Botol 68,300 1
4 Dexacef F Syrup Ferron Botol 35,000
Dexacef F Capsul Ferron Box 472,000 60
5 Widoxil Capsul Infion box 850,000 100
Cedrofen Capsul 250 mg Interbat Box 110,000 30
Cedrofen Capsul 500 mg Interbat Box 336,000 30
Cedrofen Syrup 125 mg/5 ml Interbat Botol 56,700 1
Widoxil Infion botol 38,000 1

Sefalexin 1 Cefalexin Generik Capsul 500 mg G


2 Cefabiotic Syrup 125 mg/5 ml Bernofarm
Cefabiotic Capsul 500 mg Bernofarm

Sefazolin 1 Evalin Injeksi 1 gr Soho

GENERASI II
Sefaklor 1 Cefachlor Generik Capsul 500 mg
2 Sochlor Syrup 500 mg Soho

93
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Sefuroksim 1 Cefuroxim Generik Capsul G
2 Cethixim Capsul 500mg Ethica
3 Cituroxim Kaplet 500 mg Puspa
Cituroxim Injeksi 1000 mg Puspa
4 Celocid Injeksi 750 mg Dexa Medica 3 vial 65,000 1

GENERASI III
Sefiksim 1 Cefixim Generik Syrup 100mg Hexpharm 5 box 65,000 50
Cefixim Generik Syrup 100mg/5 mL Hexpharm 20 botol 18,000 1
Cefixim Generik Tablet 200 mg Dexa Medica 4 box 385,035 100
2 Nixafen Drop 100 mg /5 ml Novell Botol 75,000 1
3 Cefspan Capsul 200mg Kalbe Farma 1 box 648,000 30
Cefspan Syrup 100 mg/ 5 ml Kalbe Farma 5 botol 92,000 1
4 Ceptik Capsul 100mg Interbat 2 box 645,000 30
5 Inbacef Capsul 200 mg Infion box 600,000 30
6 Inbacef Syrup 100 mg/ 5 ml Infion Botol 65,000 1

Sefoperazon 1 Sefoperazon Generik Injeksi 1 gr Novell


2 Yazon Injeksi 1 gr Yarindo

Seftriakson 1 Ceftriaxon Generik Injeksi 1 gr Dexa


2 Starxon Injeksi 1 gr Interbat 5 vial 207,500 1
3 Cefxon Injeksi Lapi
4 Gracef Injeksi 1 gr Gracia
6 Broadced Injeksi 1 gr Kalbe Farma 5 vial 195,000 1

Sefotaksim 1 Cefotaxim Generik Injeksi 1gr Dexa Medica 3 Vial 66,150 1


2 Taxegram Injeksi 1gr Sanbe Vial 132,450 1
3 Combicef Injeksi 1gr Combiphar 5 vial 176,000 1
4 Cepofipon Injeksi 1 gr Infion 1 Box 240,000 2
5 Rycef Injeksi 1 gr Interbat 5 vial 167,000 1

Seftazidim 1 Ceftazidime Generik Injeksi 1gr Novell 5 box 41,500 1


2 Zidifec Injeksi 1gr Sanbe 2 Vial 241,800 1
3 Lacedim Injeksi 1gr Lapi
4 Fortum Injeksi 1gr Glaxo
5 Ceftum Injeksi 0,5 gr Ferron
Ceftum Injeksi 1 gr Ferron

Seftizoksim 1 Ceftizoxime Na Generik Injeksi 1g Novell 2 box 200,000 2 vial


3 Tizos Injeksi 1 gr Dexa Medica 3 vial 201,000 1

Sefotiam 1 Ceradolan Tablet Takeda

94
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

GENERASI IV
Sefditoren pivoksil 1 Meiact Tablet 200 mg Meiji

Sefpirom 1 Sefpirom Generik Injeksi 1 gr Hexapharm 2 box 220,000 2 vial

Sefepim 1 Cefepime Generik Injeksi novell 3 box 125,000 1 vial


2 Macef Injeksi Bernofarm
3 Rapime Injeksi Fahrenheit

C. PENISILIN
Procain Penicillin G 1 Procain Penicillin G Injeksi 3.000.000 IU Meiji

Ampicillin 1 Ampicillin Generik Tablet Kimia Farma 10 box 48,395 100


Ampicillin Generik Injeksi G

Amoxycillin 1 Amoxycillin Generik Tablet 250mg Hexpharm


Amoxycillin Generik Tablet 500mg Hexpharm 10 box 33,636 100
Amoxycillin Generik Syrup Holi 50 botol 3,500 1
Amoxsan Syrup Sanbe Botol 20,710 1
Amoxsan Drop Sanbe Botol 20,710 1
Amoxsan Injeksi Sanbe Box 207,100 10
3 Intermoxil Tablet 500mg Interbat 5 box 325,000 100

Amoxycillin + Clavulanic acid 1 Co - Amoyclav Generik Tablet Dexa Medica 10 Box 126,000 30
2 Claneksi Tablet Sanbe Box 335,250 30
Claneksi Syrup Sanbe Box 534,000 6
4 Claneksi F Syrup Sanbe Botol 65,350 1
5 Clabat tablet 500mg tab Interbat 3 box 290,000 20
Clabat Syrup dry Interbat 5 botol 75,000 1

Sulbenicillin disodium 1 Kedacillin Injeksi 1 gr Takeda

Ampicillin + Sulbactam 1 Bactesyn Tablet 375mg Kalbe Farma 2 box 510,000 30


Bactesyn Injeksi 750mg Kalbe Farma 5 vial 91,000 1
2 Pycin Injeksi 1500mg Bernofarm
3 Cinam Injeksi 1500mg Sanbe 2 Vial 132,500 1

D. PENICILIN + BETA LAKTAM


Meropenem 1 Meropenem Generik Injeksi 0,5 gr Dexa Medica 3 vial 126,000 1
Meropenem Generik Injeksi 1 gr Nulab 2 vial 220,000 1
2 Merofen Injeksi 1 gr Kalbe Farma 3 vial 240,000 1
4 Merosan Injeksi 0,5 gr Sanbe 2 Vial 255,900 1

95
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Merosan Injeksi 1 gr Sanbe 2 Vial 499,600 1

Imipenem + cilastatin 1 Timipen Injeksi 1gr Interbat 5 Ampul 328,600 1


2 Pelastin Injeksi 1gr Sanbe Vial 311,000 1

E. KLORAMPENIKOL
Thiamfenikol 1 Thiamfenicol Generik Capsul 500mg Berno
2 Biothicol Capsul 250mg Sanbe Box 169,000 100
3 Lacophen Suspensi Lapi
4 Thiamycin Capsul Interbat 2 box 387,000 100
Syrup Interbat 5 botol 35,200 1

Klorampenikol 1 Chlorampenicol Generik Capsul G


Syrup G
2 Colsancetine Injeksi 1gr Sanbe Box 94,800 10
3 Chloramex Injeksi 500mg Actavis

F. MAKROLID
Erytromicin 1 Erytromicin Generik Capsul G
Erytromicin Generik Syrup G
2 Erythrin Syrup Interbat 10 botol 44,000 1
3 Erysanbe Capsul 250mg Sanbe Box 128,000 100
Erysanbe Capsul 500mg Sanbe Box 246,000 100
Erysanbe Syrup Sanbe Botol 20,400 1

Claritromycin 1 Claritromycin Generik Tablet 250 mg Novell


2 Bicrolid Tablet 250mg Sanbe

3 Abbotic XL Caplet 500mg Glaxo


4 Abbotic Syrup Glaxo
5 Comtro Syrup Combiphar 5 botol 55,000 1

Azithromycin 1 Azithromycin Generik Tablet 500 mg Novell box 270,000 30


2 Mezatrin Tablet 250mg Sanbe Box 402,900 30
3 Infimycin dry sirup Infus 200mg/5ml Infion Botol 80,000
6 Azomax Tablet Dexa Medica
Azomax Syrup Dexa Medica
7 Zycin Tablet 500 mg Interbat 10 box 106,500 3

Spiramycin 1 Spiramycin Generik Tablet


2 Profamed Tablet 500mg Promed
3 Spiranter Tablet 500mg Interbat 1 box 730,000 100
4 Spirasin Tablet 500mg Sanbe Box 553,500 100

96
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

G. KUINOLON
Ciprofloxacin 1 Ciprofloxacin Generik Tablet 500 mg Berno
2 Baquinor F Tablet Sanbe Box 252,000 20
Baquinor F Infus Sanbe Fls 215,100 1
3 Interflox Tablet 500mg Interbat 3 box 169,200 12

Ofloxacin 1 Ofloxacin Generik Tablet 400mg G


2 Prolecin Tablet 400mg Promed
3 Ethiflox Tablet 200 mg Ethicha

Levofloxacin 1 Levofloxacin Generik Tablet 500 mg Dexa


Levofloxacin Generik Infus 500 mg Novell 10 botol 84,000 1
2 Cravit Tablet 500 mg Kalbe Farma 5 box 370,000 10
Cravit Infus 500 mg Kalbe Farma 5 botol 270,000 1
3 Levocin Tablet 500 mg Sanbe Box 616,500 18
Evofion Infus 500 mg Infion Botol 190,000 1
5 Floxacom Tablet 500 mg Combiphar 10 box 278,300 10

H. TETRASIKLIN
Tetracycline 1 Tetracycline Generik Capsul 250mg G
Tetracycline Generik Capsul 500mg G
2 Tetrin Capsul 500 mg Interbat 1 box 162,000 100

Doxyciclin 1 Doxyciclin Generik Capsul 100mg G


2 Siclidon Capsul 100mg Sanbe Box 97,400 20

I. ANTI BAKTERIAL KOMBINASI


Sulfametoxazole +Trimetoprim 1 Cotrimoxazole Generik Syrup 200/40 mg G
Cotrimoxazole Generik Tablet 400/80 mg G
2 Sanprima Syrup 200/40 mg Sanbe Box 23,600 1
Sanprima Tablet 400/80 mg Sanbe Box 82,000 100
3 Sanprima F Tablet 800/160 mg Sanbe Box 184,500 100

J. ANTI BIOTIK GOL. LAIN


Clindamycin 1 Clindamycin OGB Capsul 150mg Dexa Medica
Clindamycin OGB Capsul 300mg Dexa Medica
3 Climadan Capsul 300 mg Kalbe Farma
4 Prolic Capsul 150mg Sanbe Box 328,000 100
Prolic Capsul 300mg Sanbe Box 666,500 100
5 Clinmas Capsul 300mg Lapi

97
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Lincomycin 1 Lincomycin Generik Capsul G
2 Biolincom Capsul 500 mg Otto
Biolincom Syrup 250 mg /5 ml Otto
3 Nolipo Capsul 500mg Sanbe Box 441,000 100

Vancomicin 1 Vancep Injeksi 500mg Fahrenheit

Polimiksin E sulfat 1 Colistine Tablet 1.500.000 IU Actavis

L. OBAT ANTI JAMUR


Griseofulvin 1 Griseofulvin Generik Tablet 500mg Darya Varia

Ketokonazole 1 Ketokonazole Generik Tablet 200 mg Dexa Medica 10 box 19,568 50


2 Interzol Cream Interbat 10 tube 33,920 1

Fluconazole 1 Fluconazole Generik Capsul 100 mg G


Fluconazole Generik Infus 100 mg Novell 5 botol 105,000 1
2 Cryptal Infus 200 mg Fahrenheit
Cryptal Tablet 50 mg Fahrenheit
3 Diflucan Capsul 50 mg Pfizer
4 Flucoral Capsul 50 mg Kalbe Farma 1 box 680,000 10

Itraconazole 1 Sporacid Capsul 100 mg Ferron


2 Itzol Tablet 100 mg Lapi

Nystatin 1 Fungatin Drop Ferron


2 Nymiko Drop Sanbe Botol 30,500 1
3 Kandistatin Drop Metiska
M. ANTI VIRUS
Acyclovir 1 Acyclovir Generik Tablet 200 mg Kimia Farma
Acyclovir Generik Tablet 400 mg Kimia Farma
2 Virtaz Tablet 400 mg Fahrenheit
3 Clinovir Tablet 200 mg Pharos

Isoprinosin 1 Isoprinosin Tablet Darya Varia


Syrup Darya Varia
2 Isprinol Tablet Novell
Syrup Novell

Valacyclovir 1 Inlacyl Caplet 500 mg Infion 5 Box 360,000 30

Telbivudine 1 Sebivo Tablet 600 mg Novartis

98
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Lamivudine 1 3TC-HBV Tablet 100 mg Glaxo
2 Hiviral Tablet 150 mg Kimia Farma

Zidovudine 1 Retrovir Capsul 100 mg Glaxo

Zidovudine + Lamivudine 1 Duviral Tablet 300 mg/ 150 mg Kimia Farma

Nevirapine 1 Neviral Tablet 200 mg Kimia Farma

Efavirenz 1 Efavirenz Tablet 600 mg Matrix - India


2 Estiva-600 Tablet 600 mg Hetero - India

Stavudine 1 Staviral Tablet 30 mg Kimia Farma

Tenofovir 1 Viread Tablet 300 mg Gillead


2 Tenofovir Generik Tablet 300 mg Mylan - India
3 Tenofovir Generik Tablet 300 mg Matrix - India

Tenofovir + Emtricitabine 1 Truvada Tablet 300/200 mg Gilead

Didanosine 1 Videx Tablet 125 mg Bristol-Myers Sq

Lopinavir + Ritonavir 1 Aluvia Tablet 200 mg/ 50 mg Abbott

Zidovudin + Lamivudine + Nevirapine 1 FDC Tablet Dispersi 30


FDC Tablet Dispersi 50
FDC Tablet Dispersi 60

Stavudine + Lamivudine + Nevirapine 1 Triomun Junior Tablet Dispersi 12 mg


Triomun Junior Tablet Dispersi 60 mg
Triomun Junior Tablet Dispersi 100mg

N. ANTI CACING
Pyrantel 1 Pyrantel Generik Tablet 125 mg G
2 Combantrin Tablet 125 mg
Combantrin Tablet 250 mg
Combantrin Syrup 360 mg/5 ml
3 Vermic Syrup 360 mg/5 ml Indofarma

Mebendazol 1 Vermox 500 Tablet 500 mg Janssen

O. ANTI MALARIA
Chloroquin 1 Chloroquin Generik Tablet 250 mg Kimia Farma

99
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
2 Malarex Tablet 250 mg Actavis

Kina 1 Kina Generik Tablet 500 mg Kimia Farma

Artemether 1 Artem Injeksi 80 mg/ ml Multimitra


2 Artesunate Generik Injeksi G

Primetamin 1 Primet Tablet 25 mg Kimia Farma

Sulfadoxin + Pirimetamin 1 Fansidar Tablet 500 mg/25 mg Roche

P. ANTI AMUBA
Metronidazole 1 Metronidazole Generik Tablet 500 mg Berno
Metronidazole Generik Infus 500 mg/1000 ml B Braun 5 botol 36,200 1
Metronidazole Generik syrup 125 Darya Varya 10 botol 7,912 1
2 Fladex Infus 1 gr Dexa Medica
3 Flagyl Forte Supp 1 gr Aventis
Flagyl Forte Syrup 125 mg/5 ml Aventis
4 Promuba Syrup 125 mg/5 ml Meprofarm
5 Trichodazol Infus 1 gr Sanbe Fls 82,750 1

X. SISTEM KEMIH KELAMIN

A. PREPARAT VAGINA
Metronidazole + Nistatin 1 Trichodazole Plus Ovula Vag. Tablet Sanbe Box 72,900 6
2 Vagistin Ovula Vag. Tablet Combiphar 3 box 151,250 10
3 Neo Gynoxa Vag. Tablet Kalbe Farma 2 box 138,000 10

Progesteron 1 Cygest Pesary Vag. Tablet Alpharma

Policresulen 1 Albothyl Ovula Vag. Tablet Pharos

2 Lactasid Vag Gel

B. ANTISEPTIK SALURAN KEMIH


Asam Pipemidat 1 Urinter Capsul 400mg Interbat 1 box 470,000 100
2 Urispas Capsul 200mg Indofarma
3 Urotractin Capsul 400mg Sanbe Box 181,500 60

Ekstrak Daun Tempuyung 1 Nephrolit Capsul Kalbe Farma


2 Batugin Eliksir Kimia Farma

100
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Sericocalyx folium+Orthosiphon herba 1 Renax Tablet Interbat 1 box 365,000 50

C. OBAT YANG BEKERJA PADA UTERUS


Methylergometrine 1 Metilat Tablet Metiska Farma

Synthetic Oxytocin 1 Oxytocin injeksi Novell 5 box 25,000 10


1 Induxin Injeksi Kalbe Farma 2 box 80,000 10
2 Piton-S Injeksi Organon

Isoxsuprine HCl 1 Duvadilan Injeksi Kimia Farma


2 Hystolan Tablet Dexa Medica

Allylestrenol 1 Pregnolin Tablet 5mg Dexa Medica


2 Prestrenol Tablet Interbat 1 box 205,000 50
3 Preabor Tablet 5mg Sanbe
4 Premaston Tablet 5mg Kalbe Farma 1 box 115,000 30

D. OBAT UNTUK DISFUNGSI EREKSI


Sildenafil 1 Viajoy Capsul 50 mg Otto

Vardenafil 1 Levitra Tablet 5 mg Bayer


Levitra Tablet 10 mg Bayer

E. OBAT UNTUK PENYAKIT SALURAN KEMIH & PROSTAT


Ekstrak Pumpkin seed ELFA 940 1 Inkurin Tablet 250 mg Interbat

Tamsulosin HCl 1 Harnal D Tablet Glaxo

Solifenacin Suksinat 1 Vesicare Tablet 5 mg Astellas

F. OBAT SALURAN KEMIH KELAMIN GOL. LAIN


Ketoacid 1 Aminefron Caplet Dexa Medica
2 Tonar Kaplet Sandoz
3 Renoguard Capsul Ikapharmindo
4 Nocid Capsul Kalbe Farma
5 Prorenal Capsul Novell

Tribulus terrestris 1 Tribestan Tablet 250mg Metiska Farma

Tribulus+Muira puama+Damiana+Ginseng 1 Unigen Capsul Nutrindo

Tribulus+cordioseps+Butea sup+Ginseng 1 Erefit Soft Capsul Escolab

101
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

XI. SISTEM ENDOKRIN DAN METABOLIK

A. PREPRAT INSULIN
Human Insulin Reguler Intermediate Acting 1 Actrapid HM 100 Vial 100 iu/ml 10 ml Novonordisk
2 Sansulin N Cartridge 100 iu/ml 3 ml Sanbe

Insulin Analog Rapid Acting 1 Novorapid Penfill Injeksi Novonordisk


2 Humalog R Eli Lily

Insulin Analog Premix 30/70 1 Novomix Penfill Penfill Novonordisk

Insulin Analog 25/75 1 Humalog Mix 25 Cartridge Eli Lily

Insulin Analog Long Acting/Basal 1 Levemir Penfill Penfill Novonordisk

B. ORAL ANTI DIABETES


Glibenclamid 1 Glibenclamid Generik Tablet Kimia Farma

Gliclazide 1 Diamicron MR Tablet 30mg Servier


Diamicron MR Tablet 60 mg Servier

Metformin HCl 1 Metformin HCl Generik Tablet 500 mg Hexpharm


Metformin HCl Generik Tablet 750 mg Hexpharm
2 Glucophage Tablet 500 mg Merck
3 Glumin XR Tablet 500 mg Ferron
Glumin XR Tablet 750 mg Ferron
4 Forbetes Tablet 500 mg Sanbe

Glibenclamid + Metformin HCl 1 Glucovance Tablet 1.25/250 Merck


Glucovance Tablet 2.5/500 Merck
Glucovance Tablet 5/500 Merck

Gliquidone 1 Gliquidone Generik Tablet Dexa Medica


2 Glurenorm Tablet 30mg Boehringer

Glimepiride 1 Glimepiride Generik Tablet 1mg Nulab


Glimepiride Generik Tablet 2 mg Nulab
2 Glimefion Tablet 2 mg Infion box 115,000 30
Glimefion Tablet 4 mg Infion box 175,000 30
3 Metrix Tablet 3mg Kalbe Farma 1 box 169,000 30

102
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

Pioglytazone 1 Actos Tablet 30mg Takeda

Vildagliptin + Metformin HCl 1 Galvusmet Tablet 50/500 Dexa Medica


Galvusmet Tablet 100/500 Dexa Medica

Sitagliptine 1 Januvia Tablet 50 mg MSD


Januvia Tablet 100 mg MSD

Sitagliptine + Metformin 1 Janumet Tablet 50mg / 500mg MSD

Saxagliptin + Metformin 1 Kombiglyze XR Tablet 5/500 AstraZeneca

Acarbose 1 Glubose Tablet 50 mg Ferron

C. HORMON TIROID
L-Thyroxine Na 1 Thyrax Tablet 50 mcg Granon
2 Euthyrax Tablet 50 mcg Merck

D. ANTI TIROID
Prophyltiouracyl 1 PTU Generik Tablet 50 mg G
PTU Generik Tablet 100mg G

Carbimazole 1 Neo Mercazol Tablet 5mg Nicholas

Tiamizole 1 Thyrozol Tablet 5mg Merck


Thyrozol Tablet 10mg Merck
E. OBAT ANTIOBESITAS
Orlistat 1 Xenical Capsul 120 mg Roche

F. OBAT METABOLISME TULANG


Calcitriol 1 Ostriol Capsul Lunak 0,25 mcg Fahrenheit
2 Kolkatriol Capsul Phapros

XII. VITAMIN DAN MINERAL

A. VITAMIN A, D & E
Vitamin A 1 Vitamin A Tablet 20000IU Kimia Farma
Vitamin A Tablet 50000IU Kimia Farma

Tocopherol 1 Dalfarol Capsul 100IU Nutrindo

103
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Dalfarol Capsul 400IU Nutrindo
2 Lanturol Capsul Landson

B. VITAMIN B
B1 1 Vitamin B1 Generik Tablet 50mg G
B6 2 Vitamin B6 Generik Tablet 10 mg G
B12 3 Vitamin B12 Generik Tablet G

Vitamin B Komplek 1 Vitamin B comp Generik Tablet G


2 Neurobat Forte Injeksi Interbat 3 box 180,000 20
3 Neurobion Tablet 1000 mg Merck
Neurobion Tablet 5000 mg Merck
Neurobion Injeksi 5000 mg Merck
4 Neuromed Tablet 5000 mg Promed
5 Neurosanbe Tablet 1000 mg Merck
Neurosanbe Tablet 5000 Merck
6 Becombion Syrup 110 ml Merck
7 Mersibion Injeksi 5000 mg Mersifarma

C. VITAMIN C
Ascorbid Acid 1 Vitamin C Generik Tablet 50 mg Kimia Farma
2 Extrace Injeksi 500mg Ethica

D. ASAM FOLAT 1 Folavit Tablet 1 mg Sanbe Box 164,000 100


2 Fetavita Tablet Escolab
3 Folamil genio Capsul
4 Nerva plus Tablet Gracia
5 Osfit DHA Tablet Kalbe Farma 5 box 120,000 30
6 Folaplus Tablet Meprofarm
7 Vitamam Tablet 1, 2, 3 Novell
8 Vomilat Tablet Kalbe Farma

E. MULTI VITAMIN
Vitamin E + B Komplek 1 Neurovit E Tablet Kimia Farma
2 San-B Plex Drop Sanbe Botol 16,000 1

Fursultiamin+Vit B12 1 Alinamin F Tablet Takeda


Injeksi Takeda
F. KALSIUM
1 Calnic Syrup Gracia
2 Calsium Gluconas Generik Injeksi Ethica
3 Calsium Laktat Generik Tablet Kimia Farma
4 CDR Tablet eff Bayer

104
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Tablet Bayer
5 Ossovit Tablet Interbat 2 box 252,000 60

G. MULTIVITAMIN DAN MINERAL


Bonistein+Ca+VitK+Vit D3 1 Hi-Bone Tablet Otto

Calsium dan Multi Vitamin 1 Elkana Syrup Sanbe Botol 19,850 1

Multivitamin + Mineral 1 Apyalis Drop Lapi


Syrup
2 Visebad Drop Otto

3 Cernevit Injeksi Kalbe Farma 5 box 163,000 1

4 OreZinc Sachet Novell


5 Zink Care Tablet eff Kalbe Farma
6 Zinc Pro Syrup Combiphar 5 botol 35,200 1

7 Natursif Syrup Bernofarm


8 Vitaplex Syrup Bernofarm
Vitaplex Drop
9 Provital Plus Capsul Landson
10 Becom C Tablet Sanbe Box 123,000 100
11 Becom Zet Tablet Sanbe Box 164,000 100
12 Farmabex-C Tablet Fahrenheit
13 Zegavit Tablet Kalbe Farma 3 box 115,000 50
14 Zamel Syrup Novell
15 Sim DHA Syrup Simex
16 Inlacta DHA Capsul Interbat 2 box 174,000 30
17 Prolacta DHA Capsul Novell
18 Likurmin Syrup Kalbe Farma

Multivitamin Mata
Billberry + Retinol + Vit. E 1 Berry vision Tablet Sanbe
Berry vision tablet disp Sanbe
2 Eye bright Tablet
3 Eyevit Syrup

4 Vitanorm Tablet

B-Carotene+Vit. E+Zn+Se+Lutein Ester 1 Retivit Tablet

H. ZAT BESI

105
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Sulfas Ferosus 1 Sulfas Ferosus Generik Tablet Kimia Farma
2 Biosanbe Tablet Sanbe Box 92,500 100
3 Inbion Capsul Interbat 5 box 168,000 100
4 Maltiron Capsul Meprofarm
5 Maltofer Syrup Combiphar 10 botol 66,550 1
6 Emineton Tablet Kalbe Farma 10 box 140,000 100

Iron Sucrose 1 Venofer Injeksi 100 mg Combiphar 1 box 1,017,500 5

XIII. NUTRISI

A. NUTRISI ENTERAL
1 Peptisol Box/Pack Kalbe Farma
2 Diabetasol Box/Pack Kalbe Farma
3 Nephrisol Box/Pack Kalbe Farma
4 Nitrisol Box/Pack Fahrenheit
5 Vip Albumin Capsul Royal Medicine
6 Sirplus Syrup Meprofarm

B. ELEKTROLIT DAN MINERAL


Kalium 1 Aspar K Tablet 300 mg Tanabe
2 KSR Tablet 600 mg Merck
3 Renalyte Cairan 200 mg Fahrenheit
4 Renapar Tablet 10 mg Fahrenheit

Oralit 1 Oralit Sachet Kimia Farma


2 Trolit Sachet Kalbe Farma 10 box 58,000 6
3 Renalyte Cairan 500 ml Fahrenheit
4 Pharolit Sachet Phapros

C. PERANGSANG NAFSU MAKAN


Curcuminoid 1 Apecur Syrup 100 ml Simex
2 Curvit Kaplet Soho
3 Curvit CL Emulsion Syrup 175 ml Soho

Curcuma+Papain Zingiber 1 Digezym Tablet Ethica

D. SUPLEMENT DAN TERAPI PENUNJANG


1 Anti Oksidan
1 Seloxy Kaplet Ferron
2 Lycoxy Tablet Dexa Medica
Gliadin+SOD 3 Glisodin Capsul Kalbe Farma

106
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Astaxantin Natural 4 Asthin Bond Capsul Soho
5 Oxypen Tablet Ferron

Lechitine+B plek+Vit. E+Karoten 1 Escovit Tablet Escolab

2 Imunomodulator
Malicacid+Arginin+Glysirizin+Glukosamine 1 Aviter Sachet Interbat 1 box 630,000 20

Echinasea+Zn 1 Imboost Force Capsul Soho


Imboost Force Syrup Soho

Echinasea+Kalsium Ascorbate 1 Imunvit plus Tablet Simex

Echinasea+Se+Vit. C 1 Imesco Tablet Escolab

Echinasea+ 1 Imunos Tablet Lapi


Imunos Syrup
Phyllantus Niruri L 1 Divens Syrup 25 mg/5ml Dexa Medica

Arabynoxilan derivatives 1 Biobran Tablet 250 mg Ferron

Ekstrak Plasenta+B12+Ca. Phosfate 1 Laktafit Tablet Dexa Medica

Trigonella Foenum-graecum+Sauropus andr 1 Lactamam Tablet Novell


2 Lactafar Tablet Fahrenheit

L-Glutamin 1 Glutrop Tablet 1000 mg Tropica Mas

XIV. MATA

A. ANTIINFEKSI & ANTISEPTIK MATA


Levofloxacin 1 Cravit Tetes Mata Ferron
2 LFX Mini Dose 0,6 ml Cendo

Ofloxacin 1 Tarivid Tetes Mata Kalbe Farma

Moxyfloxacin 1 Vigamox Tetes Mata 0,5% Alcon

Oxytetra 1 Oxytetracyclin Generik Eye Oint 1% 3.5 gr Kimia Farma

Chloramfenicol 1 Chloramfenicol Generik Eye Oint G


Chloramfenicol Generik Tetes Mata G

107
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
2 Cendo Fenicol Salep Mata
3 Kemicetine Salep Mata 1% 5 gr Kalbe Farma
Kemicetine Tetes Mata 0,5% 5 ml Kalbe Farma

Gentamycin 1 Gentamycin Generik Salep Mata G


2 Cendo Genta Salep Mata CENDO
Cendo Genta Tetes Mata CENDO

Dibekacin Sulfate 1 Dibekacin Tetes Mata Meiji

Polymicin sulfate + Gramicidine 1 Cendo polygran Salep Mata Cendo


Cendo polygran Tetes Mata Cendo

Acyclovir 1 Cendo Hervis Salep Mata Cendo

Asam Fusidat 1 Cendo Pipthalmic Salep Mata Cendo

Natamicin 1 Natacen Tetes Mata

B. ANTISEPTIK MATA DENGAN KORTIKOSTEROID


Tobramycin + Dexametason 1 Cendo Tobroson Salep Mata Cendo
2 Cendo Tobroson MD TM Mini Dose
Dexametason + Neo + Polymicin 1 Cendo Xytrol Salep Mata Cendo
Cendo Xytrol Tetes Mata 5 ml
Polinicin+Neo+Gramycidin 1 Cendo Polydex Mini Dose Cendo

C. KORTIKOSTEROID MATA
-

D. OBAT MIDRIATIKUM
Tropicamide 1 Cendo Midriatil Tetes Mata 1% 5ml Cendo

E. OBAT MIOTIKUM
Sulfas Atropin 1 Cendo Tropin Tetes Mata 0,5 % Cendo

F. PREPARAT ANTIGLAUKOMA
Timolol Maleate 1 Cendo Timol Tetes Mata Cendo

Betaxolol 1 Tonor Tetes Mata 5.00% Cendo

Acetazolamide 1 Glaucon Tablet

108
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
G. OBAT DEKONGESTAN, ANESTESI, ANTIINFLAMASI MATA
Pemirolast Protasium 1 Allegysal Tetes Mata 2% 5 ml Ferron

Diclofenac Na 1 Flamar Tetes Mata SANBE tube 15,200 1

Vit. A+Zinex+Phenylephrine 1 Cendo Augentonic MD Tetes Mata Cendo

Neomycine + Polymicine +Phenylephrine 1 Cendo Statrol Tetes Mata Cendo

Tetracaine 1 Cendo Pantocain Tetes Mata 0.5% 5ml Cendo


Cendo Pantocain Tetes Mata 2% 5 ml Cendo

Polyvinylpyrolidone 1 Protagenta MD Mini Dose Cendo

H. PELUMAS MATA
N-acetylcarnocine 1 Clarastill Tetes Mata Kalbe Farma

glycerol+tyloxapol 1 Cationorm Tetes Mata Kalbe Farma

Dextran + hypromellose 1 Sanbe Tears Tetes Mata Sanbe

Hydropropyl methylcelluloce+Retinol P 1 Lubricent Salep Mata

Vit. A+Aneurin hydrocloride+Ca. Panto T 1 Rephitel Salep Mata

I. PREPARAT MATA GOL. LAIN


Cromolyn Sodium 1 Conver MD Mini Dose Cendo

K-iodida + Na-Iodida 1 Vitrolenta Tetes Mata 5 mg Cendo


2 Cendo Catarlent

Sodium Hyaluronate 1 Hyalub Mini Dose 5 mg Cendo

Pironoxine 1 Lentikular Tetes Mata Cendo

Carboxymethil Cellulose Sodium 1 Cenfresh Tetes Mata Cendo

XV. TELINGA DAN MULUT/TENGGOROKAN

A. ANTIINFEKSI & ANTISEPTIK


Ofloxacin 1 Akilen Tetes Telinga Sanbe
2 Tarivid Otic Tetes Telinga Kalbe Farma 1 box 77,000 1

109
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

B. ANTISEPTIK DAN KORTIKOSTEROID


Polymixine+Neomycine+Fludrocortison+lidoca 1 Otopain Tetes Telinga Interbat 5 botol 56,000 1
2 Otilon Tetes Telinga Sanbe

Polymixine+Neomycine+Betametason+lidocai 1 Otozambon Tetes Telinga Zambon

C. PREPARAT TELINGA GOL. LAIN


Docusate Na 1 Forumen Tetes Telinga Sanbe

D. PREPARAT MULUT/TENGGOROKAN
Triamcinolone Acetonide 1 Ketricin Tablet Ferron
Ketricin Gel Ferron
2 Kenalog Cream Taisho
3 Solcoseryl Gel 5 gr Pharos

Benzydamine HCl 1 Tantum verde Kumur 120 ml Soho

Hyaluronic Acid 1 Sanorin Kumur

2 Albothyl Solution Pharos

3 Betadine Kumur 190 ml Kimia farma

XVI. KULIT

A. ANTIBIOTIK TOPIKAL
Neomycin + Ekstrak Plasenta 1 Bioplacenton Gel Kalbe Farma

Ekstrak Plasenta + B12 1 Lactasid Dewasa Solution Sanofi


2 Lactasid Bayi Sanofi

Silver Sulfadiazine 1 Burnazin Cream Darya Varia

Chloramfenicol 1 Chloramfenicol Generik Salep G


2 Kalmicetin Cream Kalbe Farma

Gentamycin 1 Garamycin Cream 0,1% Schering


2 Gentamycin Generik Cream 0,1% G

Neomycin Bacitracin 1 Nebacetin Salep Pharos


Nebacetin powder Pharos

110
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Oxytetra 1 Oxytetracyxlin Generik Salep G

Mupirocin 1 Bactroban Salep 2% 10gr Glaxo


2 Pibaksin Salep 2% 10gr Sanbe tube 38,000 1

Fusidic Acid 1 Fusycom Cream Combiphar 2 tube 44,000 1

B. KORTIKOSTEROID TOPIKAL
Momethasone 1 Elocon Cream Schering
2 Motaderm Cream Bernofarm

Betamethasone 1 Betamethasone Generik Cream Kimia Farma

Fluosinolon 1 Cinolon Cream Sanbe

Hydrocortison 1 Hydrocortison Generik Cream Kimia Farma

Desoximethasone 1 Esperson Cream Aventis


2 Inerson Cream Interbat 3 tube 65,000 1

Desonide 1 Apolar Cream Alpharma

C. ANTIJAMUR & ANTIPARASIT TOPIKAL


Miconazole Nitrat 1 Miconazole Generik Cream Kimia Farma

Ketoconazole 1 Ketoconazole Generik Hexpharm


2 Mycoral Cream Kalbe Farma
3 Interzol Cream Interbat 5 tube 22,000 1

Nystatin+Zinc Oxide 1 Myco Z Cream

Lindane+Usnic Acid 1 Scabicid Cream Kimia Farma

Sulfur 1 Salep 2-4 Salep Kimia Farma

D. ANTIVIRUS TOPIKAL
Acyclovir 1 Acyclovir Generik Cream Kimia Farma
2 Zoter Cream Interbat 10 tube 44,000 1
3 Virtaz Cream Fahrenheit

E. ANTIINFEKSI TOPIKAL DENGAN KORTIKOSTEROID


Desonide+Neomycine Sulphate 1 Apolar N Cream Alpharma

111
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
2 Desolex - N Cream

Fluosinolon+Neomycine Sulphate 1 Cinolon - N Cream Sanbe tube 16,600 1

Clotrimazol+Betamethason 1 Lotriderm Cream Schering

F. PREPARAT AKNE
Clindamycin + Tretinoid 1 Mediklin TR Cream 15 gr Suryaderm

Clindamycin+Zn Acetate 1 Climadan Acne Cream 15 gr Kalbe Farma

G. ANTIHISTAMIN/ANTIPRURITUS TOPIKAL
1 Caladin Lotion
2 Caladril Powder

H. PREPARAT PSORIASIS, SEBOROIK, & IKTIOSIS

I. KERATOLITIK
Ektrak Camomile 1 Kamillosan Cream Asta Medica

Asam Salisilat 1 Asam salisilat Solution 3%

J. EMOLIEN & PELINDUNG KULIT


Etilhexil-metoxinamat+Titanium+Oxybenzon 1 Parasol Cream 20 gr SDM

K. ANTISEPTIK & DESINFEKTAN KULIT


Ichtamol 1 Ichtiyol-Zalf Tube 10% 15 gr Nufarindo

2 Betadine Solution 60ml Mahakam


Betadine Salep Mahakam
3 Iodin Povidone Solution 30ml Kimia Farma
Iodin Povidone Solution 60ml Kimia Farma
4 Rivanol Solution 60ml Kimia Farma

Kalium Permanganat 1 PK Powder 5 gr

L. KASA MENGANDUNG OBAT


Framycetin Sulfat 1 Daryantull Pack Darya Varia

Kasa Polyester+Eco Honey+Glycerol 1 Sanoskin Melladerm Plus Tule Pack Interbat

Hydrocellular Poyurethane 1 Sanoskin Foam Pack Interbat

112
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA

Collagen Sponge 1 Collacure Pack Nufarindo

M. OBAT KULIT LAIN


Cepalin Extra+Allantoin 1 Mederma Gel 20 gr Combiphar 3 tube 181,500 1

Radix Stutellariae+Phelladendri Cartex+Rhiz 1 Mebo Cream 20 gr Combiphar 10 tube 84,700 1

Anhydrous Lanolin+Isopropyl myristate 1 Decubal Cream 20 gr Actavis

Hypoallergenic ambiphilip cream base 1 Biocream Cream Merck

Eco honey+glycerin+propilene glicol+PEG 1 Sanoskin Melladerm Plus Gell Plus Interbat

Oxygen converted 1 Sanoskin Oxy Gell 30 gr Interbat

Daktarin Diapers Cream Bayer

XVII. ANESTESI LOKAL & UMUM

Bupivacaine heavy 1 Bupivacain injeksi 5mg/ml Novell 2 box 117,500 5

Ketamine

XVIII. ANTI ALERGI & SISTEM IMUN

A. ANTI HISTAMIN DAN ANTI ALERGI


Loratadine 1 Alloris Syrup 10 mg SANBE Botol 50,000 1

Loratadine Micronize 1 Claritin Tablet Schering

Cetirizine 1 Cetirizine Generik Tablet Nulab


2 Histrin Syrup Ferron
3 Falergi Tablet Fahrenheit
4 Cetinal Syrup Kalbe Farma 5 botol 50,000 1
Tablet Kalbe Farma 3 box 140,000 30
5 Intrizin Tablet Interbat 3 box 171,000 30
Syrup
Bethametasone + Dexlorpheniramin 1 Celestamine Tablet Schering
Celestamine Syrup Schering
2 Cortamine Syrup Interbat 5 botol 43,000 1
3 Colergis Tablet Dexa Medica

113
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
Colergis Syrup Dexa Medica

Dexametasone + Dexchlorpheniramin 1 Dextamine Tablet Papros

Dimenthinden maleat 1 Fenistil Drop Novartis


Fenistil Syrup Novartis

Chlortrimeton 1 CTM Generik Tablet ESA

Dexametasone 1 Dexametasone Generik Tablet 0.5 mg ESA


Dexametasone Generik Injeksi 0.5 mg Phapros/rajawali
2 Indexon Injeksi 0.5 mg Interbat

Prednison 1 Prednison GeneriK Tablet 5 mg Bernofar

Metil prednisolon 1 Metil Prednisolon GeneriK Tablet 4 mg Nulab


Tablet 8 mg Nulab
injeksi
4 Hexilon Tablet 8mg Kalbe Farma 3 box 129,000 30
5 Medixon Injeksi 125 mg Ferron 75,000 1
Medixon tablet 4mg Ferron box 230,000 100
Medixon tablet 16mg Ferron box 170,000 30

Triamcinolone acetonide 1 Flamicort Injeksi Dexa Medica

B. VAKSIN, ANTISERUM, & IMUNOLOGIKAL


-
C. IMUNOSUPRESAN
-

XIX. ANTIDOTUM DAN ZAT DETOKSIFIKASI

N-Acetylcysteine 1 Hidonac Infus 200mg/ml Zambon

Kalsium Polystyren Sulfonat 1 Kalitake Sachet 5 gr Dipa

Lantanum Karbonat 1 Fosrenol Tablet Kunyah 500 mg Fahrenheit

XX. LARUTAN INTRAVENA & LARUTAN STERIL LAIN

Albumin Manusia 1 Plasbumin 5% Infus 250ml Dipa

114
f

DRAFT DAFTAR FORMULARIUM


RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan Farmasi Jumlah Kemasan @HARGA ISIAN HARGA
2 Octalbin 20% Infus 50ml Kalbe Farma 2 fls 750,000 1
Octalbin 20% Infus 100ml Kalbe Farma 2 fls 1,500,000 1
3 Human Albumin Behring 20% Infus 50ml Dexa Medica
4 Albumin Human 20% Infus 100ml Kima Farma
5 Plasbumin 25% Infus 50ml Dipa
Plasbumin 25% Infus 100ml Dipa
6 Albuminar 25% Infus 100ml Dexa Medica

115
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

1 Depakene Syrup 250 mg/5 ml 1 Abbot


1 Depakote ER Tablet 500 mg 2 Abbot
1 Rhytmonorm Tablet 150 mg 3 Abbott
1 Isoptin SR Tablet 240 mg 4 Abbott
1 Aluvia Tablet 200 mg/ 50 mg 5 Abbott
1 Dopamet Tablet 250 mg 1 Actavis
3 Stesolid Injeksi 10 mg 2 Actavis
Stesolid Suppos 5mg 3 Actavis
Stesolid Suppos 10mg 4 Actavis
3 Chloramex Injeksi 500mg 5 Actavis
1 Colistine Tablet 1.500.000 IU 6 Actavis
2 Malarex Tablet 250 mg 7 Actavis
1 Decubal Cream 20 gr 8 Actavis
1 Vigamox Tetes Mata 0,5% 1 Alcon
2 Longatin Capsul 1 Alpharma
2 Dumin Supp 125 mg 2 Alpharma
Dumin Supp 250 mg 3 Alpharma
1 Cygest Pesary Vag. Tablet 4 Alpharma
1 Apolar Cream 5 Alpharma
1 Apolar N Cream 6 Alpharma
1 Kamillosan Cream 1 Asta Medica
1 Perdipine injeksi Injeksi 10 mg / 10 ml 1 Astellas
1 Vesicare Tablet 5 mg 2 Astellas
1 Crestor Tablet 1 Astra
1 Nexium Kapsul 20 mg 1 AstraZeneca
Nexium Kapsul 40 mg 2 AstraZeneca
Nexium Injeksi 40 mg 3 AstraZeneca
1 Kombiglyze XR Tablet 5/500 4 AstraZeneca
1 Symbicort Turbo Heler Inhaler 60 dosi 80/4.5 5 AstraZenica
Symbicort Turbo Heler Inhaler 60 dosi 160/4.5 6 AstraZenica
1 Pulmicort Nebulizer 7 AstraZenica
3 Lasix Tablet 40 mg 1 Aventis
Lasix Injeksi 20 mg / ml 2 Aventis
4 Claforan Injeksi 1 gr 3 Aventis
3 Flagyl Forte Supp 1 gr 4 Aventis
Flagyl Forte Syrup 125 mg/5 ml 5 Aventis
3 Amaryl Tablet 2mg 6 Aventis
1 Esperson Cream 7 Aventis
2 Adalat Oros 30 mg 1 Bayer
1 Nimotop Injeksi 10 mg/50 ml 2 Bayer
1 Cyclo-Progynova Tablet 3 Bayer
1 Microlut Tablet 30 mcg 4 Bayer
1 Mycroginon Tablet 5 Bayer
1 Yasmin Tablet 6 Bayer
2 Yaz Tablet 7 Bayer
1 Angeliq Tablet 8 Bayer
1 Andalan Tablet 9 Bayer
1 Levitra Tablet 5 mg 10 Bayer
Levitra Tablet 10 mg 11 Bayer
4 CDR Tablet eff 12 Bayer
Tablet 13 Bayer
Daktarin Diapers Cream 14 Bayer
1 Antidia Tablet 2 mg 15 Berno
2 Loperamid Generik Tablet 16 Berno
2 Metolon Tablet 5 mg 17 Berno
Metolon Tablet 10 mg 18 Berno
Metolon Injeksi 10 mg/2 ml 19 Berno
1 Simvastatin Generik Tablet 10mg 20 Berno
Simvastatin Generik Tablet 20mg 21 Berno
1 Amoxycillin Generik Tablet 250mg 22 Berno
Amoxycillin Generik Tablet 500mg 23 Berno
1 Ciprofloxacin Generik Tablet 500 mg 24 Berno
1 Natrium diklofenac Generik Tablet 25mg, 50 mg 25 Bernofar
Omeprazole Generik Injeksi 26 Bernofarm
3 Inhipraz Capsul 30 mg 27 Bernofarm
Pantoprazol Generik Injeksi 28 Bernofarm

116
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

1 Sulcolon Tablet 500 mg 29 Bernofarm


Domperidone Generik Syrup 30 Bernofarm
5 Nomesis Drop 31 Bernofarm
2 Kliran Injeksi 4 mg 32 Bernofarm
Kliran Injeksi 8 mg 33 Bernofarm
2 Lovask Tablet 10 mg 34 Bernofarm
4 Asam Tranxamat generik Tablet 250 mg 35 Bernofarm
Asam Tranxamat generik Tablet 500 mg 36 Bernofarm
2 Anafen Syrup 100 mg/5ml, 60 ml 37 Bernofarm
1 Trolac Kaplet 10 mg 38 Bernofarm
Injeksi 30 mg/ml 39 Bernofarm
1 Neurogen Tablet 500 mg 40 Bernofarm
5 Benocetam Injeksi 3 gr/15 ml 41 Bernofarm
3 Benoxuric Tablet 300mg 42 Bernofarm
2 Ofertil Tablet 50mg 43 Bernofarm
3 Simikan Injeksi 250 mg/2 ml 44 Bernofarm
1 Cefadroxil Generik Capsul 500mg 45 Bernofarm
Cefadroxil Generik Syrup 46 Bernofarm
2 Cefabiotic Syrup 125 mg/5 ml 47 Bernofarm
Cefabiotic Capsul 500 mg 48 Bernofarm
7 Tocef Syrup 100 mg/ 5 ml 49 Bernofarm
2 Macef Injeksi 50 Bernofarm
2 Pycin Injeksi 1500mg 51 Bernofarm
4 Zistic Capsul 500mg 52 Bernofarm
Zistic Syrup 53 Bernofarm
4 Glucoryl Tablet 2mg 54 Bernofarm
7 Natursif Syrup 55 Bernofarm
8 Vitaplex Syrup 56 Bernofarm
8 Natavit Capsul 57 Bernofarm
2 Motaderm Cream 58 Bernofarm
2 Buscopan Plus Tablet 59 Boehringer
3 Dulcolactol Syrup 60 Boehringer
1 Dulcolax Tablet 61 Boehringer
Dulcolax Suppos 5 mg 62 Boehringer
Dulcolax Suppos 10 mg 63 Boehringer
2 Laxoberon Drop 64 Boehringer
1 Micardis Tablet 40 mg 65 Boehringer
1 Twynsta Tablet 40/5 mg 66 Boehringer
2 Catapres Tablet 75/150 mcg 67 Boehringer
Catapres injeksi 150 mg 68 Boehringer
1 Pradaxa Capsul 75 mg 69 Boehringer
Pradaxa Capsul 150 mg 70 Boehringer
1 Combivent Nebuls 0.5mg/2.5mg 71 Boehringer
1 Bisolvon Tablet 4 mg 72 Boehringer
Bisolvon Tablet 8 mg 73 Boehringer
Bisolvon Injeksi 2mg/ml 74 Boehringer
2 Glurenorm Tablet 30mg 75 Boehringer
1 Videx Tablet 125 mg 76 Bristol-Myers Sq
2 LFX Mini Dose 0,6 ml 77 Cendo
2 Cendo Genta Salep Mata 78 CENDO
Cendo Genta Tetes Mata 79 CENDO
1 Cendo polygran Salep Mata 80 Cendo
Cendo polygran Tetes Mata 81 Cendo
1 Cendo Hervis Salep Mata 82 Cendo
1 Cendo Pipthalmic Salep Mata 83 Cendo
1 Cendo Tobroson Salep Mata 84 Cendo
1 Cendo Xytrol Salep Mata 85 Cendo
1 Cendo Polydex Mini Dose 86 Cendo
1 Cendo Midriatil Tetes Mata 1% 5ml 87 Cendo
1 Cendo Tropin Tetes Mata 0,5 % 88 Cendo
1 Cendo Timol Tetes Mata 89 Cendo
1 Tonor Tetes Mata 5.00% 90 Cendo
1 Cendo Augentonic MD Tetes Mata 91 Cendo
1 Cendo Statrol Tetes Mata 92 Cendo
1 Cendo Pantocain Tetes Mata 0.5% 5ml 93 Cendo
Cendo Pantocain Tetes Mata 2% 5 ml 94 Cendo
1 Protagenta MD Mini Dose 95 Cendo

117
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

1 Conver MD Mini Dose 96 Cendo


1 Vitrolenta Tetes Mata 5 mg 97 Cendo
1 Hyalub Mini Dose 5 mg 98 Cendo
1 Lentikular Tetes Mata 99 Cendo
1 Cenfresh Tetes Mata 100 Cendo
2 Cendo Fenicol Salep Mata 101 Cendo
2 Neo K Injeksi 102 Combi
4 Ulsafat Susp 100 cc 103 Combiphar
Ulsafat Susp 200 cc 104 Combiphar
2 Librax Tablet 105 Combiphar
2 Constipen Syrup 120 ml 106 Combiphar
1 Hepa-Merz Sachet Granul 107 Combiphar
Hepa-Merz Injeksi 108 Combiphar
1 Somatostatin Lyomark Injeksi 250 mcg/3 mg 109 Combiphar
1 Tanakan Tablet 110 Combiphar
1 Lipanthyl Tablet 200mg 111 Combiphar
4 Mucotein Capsul 300 mg 112 Combiphar
5 Mucotein DS Syrup 175mg/5 ml 113 Combiphar
1 Comtusi Syrup 60 ml 114 Combiphar
2 Phental Injeksi 115 Combiphar
4 X-Flam Tablet 50 mg 116 Combiphar
2 Artrilox Tablet 15 mg 117 Combiphar
5 Comsporin Capsul 200 mg 118 Combiphar
5 Tyason Injeksi 1 gr 119 Combiphar
3 Combicef Injeksi 1gr 120 Combiphar
3 Comsikla Capsul 121 Combiphar
5 Floxacom Tablet 500 mg 122 Combiphar
2 Vagistin Ovula Vag. Tablet 123 Combiphar
6 Zinc Pro Syrup 124 Combiphar
7 Maltofer Syrup 125 Combiphar
1 Venofer Injeksi 100 mg 126 Combiphar
1 Fusycom Cream 127 Combiphar
1 Mederma Gel 20 gr 128 Combiphar
1 Mebo Cream 20 gr 129 Combiphar
5 Comtro Syrup 130 Combiphar
1 Levopront Syrup 60 ml 131 Combipharm
2 Citaz Tablet 50mg 132 Dankos
2 Ozid Injeksi 20 mg 133 Darya Varia
1 Budenofalk Capsul 3 mg 134 Darya Varia
1 Enzyplex Tablet 135 Darya Varia
1 Urdafalk Tablet 250 mg 136 Darya Varia
1 Kendaron Injeksi 150 mg / 3ml 137 Darya Varia
3 Cedocard Tablet 5 mg 138 Darya Varia
Cedocard Tablet 10 mg 139 Darya Varia
Cedocard Injeksi 10 mg / 10 ml 140 Darya Varia
5 Theravask Tablet 5 mg 141 Darya Varia
Theravask Tablet 10 mg 142 Darya Varia
3 Lifezar Tablet 50 mg 143 Darya Varia
Lifezar Tablet 100 mg 144 Darya Varia
1 Bronchophyllin Syrup 100 cc 150 mg/15 ml 145 Darya Varia
3 Profertil Tablet 50mg 146 Darya Varia
1 Isoprinosin Tablet 147 Darya Varia
Syrup 148 Darya Varia
1 Burnazin Cream 149 Darya Varia
1 Daryantull Pack 150 Darya Varia
1 Ondansentron Generik Injeksi 4 mg 151 Dexa
Ondansentron Generik Injeksi 8 mg 152 Dexa
1 Diltiazem Generik Tablet 30 mg 153 Dexa
Diltiazem Generik Tablet 60 mg 154 Dexa
1 Captopril Generik Tablet 12,5 mg 155 Dexa
Captopril Generik Tablet 25 mg 156 Dexa
Captopril Generik Tablet 50 mg 157 Dexa
1 Ramipril generik Tablet 5 mg 158 Dexa
1 Bisoprolol Generik Tablet 5 mg 159 Dexa
1 Nifedipin Generik Tablet 10 mg 160 Dexa
Asam Tranxamat generik injeksi 250 mg 161 Dexa
Asam Tranxamat generik injeksi 500 mg 162 Dexa

118
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

1 Clopidogrel Generik Tablet 75 mg 163 Dexa


1 Alprazolam Generik Tablet 0.5mg 164 Dexa
Alprazolam Generik Tablet 1mg 165 Dexa
1 Ceftriaxon Generik Injeksi 1 gr 166 Dexa
1 Levofloxacin Generik Tablet 500 mg 167 Dexa
Levofloxacin Generik Infus 500 mg 168 Dexa
4 Vomizol Injeksi 169 Dexa Medica
Vomizol 170 Dexa Medica
2 Lacidofil Capsul 171 Dexa Medica
1 Spasmomen Tablet 172 Dexa Medica
1 SNMC Injeksi 173 Dexa Medica
2 Vometa Syrup 60 ml 174 Dexa Medica
Vometa Tablet 10 mg 175 Dexa Medica
Vometa Drop 176 Dexa Medica
1 Anvomer B6 Tablet 177 Dexa Medica
2 Somatostatin Eumedica Injeksi 250 mcg/3 mg 178 Dexa Medica
1 Dobuject Injeksi 250 mg 179 Dexa Medica
5 Cordila SR Tablet 180 mg 180 Dexa Medica
4 Tensivask Tablet 10 mg 181 Dexa Medica
1 Nebilet Tablet 5 mg 182 Dexa Medica
1 Candesartan Generik Tablet 8mg 183 Dexa Medica
Candesartan Generik Tablet 16 mg 184 Dexa Medica
3 Canderin Tablet 8mg 185 Dexa Medica
Canderin Tablet 16 mg 186 Dexa Medica
1 Raivas Injeksi 4 mg 187 Dexa Medica
1 Atorvastatin Generik Tablet 10 mg 188 Dexa Medica
2 Stator Tablet 20mg 189 Dexa Medica
1 Streptase Injeksi 1.500.000 IU 190 Dexa Medica
3 Vectrin Syrup 175 mg/5 ml 191 Dexa Medica
2 Rhinos SR Capsul 192 Dexa Medica
3 Rhinos Neo Drop 193 Dexa Medica
4 Rhinos Junior Syrup 194 Dexa Medica
1 Rhinofed Tablet 195 Dexa Medica
1 Mertigo Tablet 8 mg 196 Dexa Medica
4 Pondex Tablet 250 mg, 500 mg 197 Dexa Medica
2 Pronalges Tablet 50 mg 198 Dexa Medica
Pronalges Tablet 100 mg 199 Dexa Medica
Pronalges Supp 100 mg 200 Dexa Medica
Pronalges Injeksi 100 mg / 2ml 201 Dexa Medica
3 Pronalges CR Tablet 200 mg 202 Dexa Medica
1 Degrium Tablet 5 mg 203 Dexa Medica
1 Norelut Tablet 5mg 204 Dexa Medica
4 Provula Tablet 50mg 205 Dexa Medica
1 Amikasin Sulfat Generik Injeksi 250 mg/2 ml 206 Dexa medica
4 Dexacef F Syrup 207 Dexa Medica
Dexacef F Capsul 208 Dexa Medica
4 Celocid Injeksi 750 mg 209 Dexa Medica
3 Tizos Injeksi 1 gr 210 Dexa Medica
1 Co - Amoyclav Generik Tablet 211 Dexa Medica
6 Dexyclav Tablet 212 Dexa Medica
6 Azomax Tablet 213 Dexa Medica
Azomax Syrup 214 Dexa Medica
1 Clindamycin OGB Capsul 150mg 215 Dexa Medica
Clindamycin OGB Capsul 300mg 216 Dexa Medica
2 Fladex Infus 1 gr 217 Dexa Medica
2 Hystolan Tablet 218 Dexa Medica
1 Pregnolin Tablet 5mg 219 Dexa Medica
1 Aminefron Caplet 220 Dexa Medica
1 Gliquidone Generik Tablet 221 Dexa Medica
1 Galvusmet Tablet 50/500 222 Dexa Medica
Galvusmet Tablet 100/500 223 Dexa Medica
2 Lycoxy Tablet 224 Dexa Medica
1 Divens Syrup 25 mg/5ml 225 Dexa Medica
1 Laktafit Tablet 226 Dexa Medica
3 Colergis Tablet 227 Dexa Medica
Colergis Syrup 228 Dexa Medica
1 Flamicort Injeksi 229 Dexa Medica

119
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

3 Human Albumin Behring 20% Infus 50ml 230 Dexa Medica


6 Albuminar 25% Infus 100ml 231 Dexa Medica
1 Kalitake Sachet 5 gr 232 Dipa
1 Plasbumin 5% Infus 250ml 233 Dipa
5 Plasbumin 25% Infus 50ml 234 Dipa
Plasbumin 25% Infus 100ml 235 Dipa
1 Mucosta Tablet 100 mg 236 Eisai
1 Aricept Tablet 5 mg 237 Eisai
2 Merislon Tablet 12 mg 238 EISAI
4 Methycobalt Capsul 250 mcg 239 Eisai
Methycobalt Injeksi 500 mcg 240 Eisai
1 Myonal Tablet 50 mg 241 Eisai
2 Humalog R 242 Eli Lily
1 Humalog Mix 25 Cartridge 243 Eli Lily
1 Antasida Generik Tablet 244 Erela
Antasida Generik Syrup 60 ml 245 Erela
1 Piroxicam Generik Capsul 10 mg 246 Esa Indo
Piroxicam Generik Capsul 20 mg 247 Esa Indo
1 Fibrinase Kapsul 248 Escolab
8 Ximesco Capsul 200mg 249 Escolab
1 Erefit Soft Capsul 250 Escolab
2 Fetavita Tablet 251 Escolab
1 Escovit Tablet 252 Escolab
1 Imesco Tablet 253 Escolab
2 Caprol Injeksi 254 Ethica
2 Cethixim Capsul 500mg 255 Ethica
2 Extrace Injeksi 500mg 256 Ethica
1 Digezym Tablet 257 Ethica
3 Ethiflox Tablet 200 mg 258 Ethicha
1 Recolfar Tablet 0.5 mg 259 Fahreinheit
6 Farlev Infus 750 mg 260 Fahreinheit
1 Impepsa Susp 261 Fahrenheit
3 Sysmuco Tablet 100 mg 262 Fahrenheit
5 Prazotec Capsul 263 Fahrenheit
1 Gastrul Tablet 264 Fahrenheit
1 Renagas Tablet 265 Fahrenheit
2 Gasflat Tablet 266 Fahrenheit
3 Sotatic Tablet 10 mg 267 Fahrenheit
Sotatic Injeksi 5 mg/ml, 2 ml 268 Fahrenheit
2 Fargoxin Tablet 0.25 mg 269 Fahrenheit
Fargoxin Injeksi 0.5 mg/2 ml 270 Fahrenheit
2 Tiaryt Tablet 200 mg 271 Fahrenheit
2 Farsorbid Tablet 5 mg 272 Fahrenheit
Farsorbid Tablet 10 mg 273 Fahrenheit
4 Farmabes Injeksi 5 mg/ml, 5 ml 274 Fahrenheit
Farmabes Tablet 275 Fahrenheit
1 Renacardon Tablet 5 mg 276 Fahrenheit
Renacardon Tablet 10 mg 277 Fahrenheit
2 Farmadral Tablet 10 mg 278 Fahrenheit
1 Farnormin Tablet 50 mg 279 Fahrenheit
1 Iretensa Tablet 150 mg 280 Fahrenheit
2 Farsix Tablet 40 mg 281 Fahrenheit
Farsix Injeksi 20 mg / ml 282 Fahrenheit
2 Carpiaton Tablet 100 mg 283 Fahrenheit
2 Vascon Injeksi 4 mg 284 Fahrenheit
1 Cartrilet Tablet 250 mg 285 Fahrenheit
1 Fluxum Injeksi 0,4 cc 286 Fahrenheit
Fluxum Injeksi 0,6 cc 287 Fahrenheit
2 Pladogrel Tablet 75 mg 288 Fahrenheit
1 Simarc-2 Tablet 2 mg 289 Fahrenheit
2 Farbivent Nebuls 0.5mg/2.5mg 290 Fahrenheit
1 Zolmia Tablet 10 mg 291 Fahrenheit
4 Farmadol Infus 1000 mg 292 Fahrenheit
Farmadol Tablet 500 mg 293 Fahrenheit
2 Fendex Injeksi 50 mg/2 ml 294 Fahrenheit
5 Renasistin Drop 295 Fahrenheit
Renasistin 296 Fahrenheit

120
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

3 Rapime Injeksi 297 Fahrenheit


3 Zifin Tablet 298 Fahrenheit
1 Vancep Injeksi 500mg 299 Fahrenheit
2 Cryptal Infus 200 mg 300 Fahrenheit
Cryptal Tablet 50 mg 301 Fahrenheit
2 Virtaz Tablet 400 mg 302 Fahrenheit
1 Ostriol Capsul Lunak 0,25 mcg 303 Fahrenheit
6 Calos Tablet 500 mg 304 Fahrenheit
12 Farmabex-C Tablet 305 Fahrenheit
4 Nitrisol Box/Pack 306 Fahrenheit
3 Renalyte Cairan 200 mg 307 Fahrenheit
4 Renapar Tablet 10 mg 308 Fahrenheit
3 Renalyte Cairan 500 ml 309 Fahrenheit
2 Lactafar Tablet 310 Fahrenheit
3 Virtaz Cream 311 Fahrenheit
3 Falergi Tablet 312 Fahrenheit
1 Fosrenol Tablet Kunyah 500 mg 313 Fahrenheit
3 Magalat Susp 314 Ferron
2 Hyperil 5 mg Tablet 5 mg 315 Ferron
2 Crome Injeksi 50 mg 316 Ferron
Crome Tablet 10 mg 317 Ferron
1 Edotin Capsul 300 mg 318 Ferron
2 Feprax Tablet 0,5mg 319 Ferron
2 Ganin Tablet 300mg 320 Ferron
3 Mecox Tablet 15 mg 321 Ferron
1 Ketesse Tablet 322 Ferron
Ketesse Injeksi 323 Ferron
4 Fepiram Injeksi 3gr/15ml 324 Ferron
Fepiram Infus 12gr/60 m 325 Ferron
5 Ceftum Injeksi 0,5 gr 326 Ferron
Ceftum Injeksi 1 gr 327 Ferron
1 Sporacid Capsul 100 mg 328 Ferron
1 Fungatin Drop 329 Ferron
3 Glumin XR Tablet 500 mg 330 Ferron
Glumin XR Tablet 750 mg 331 Ferron
1 Glubose Tablet 50 mg 332 Ferron
1 Seloxy Kaplet 333 Ferron
5 Oxypen Tablet 334 Ferron
1 Biobran Tablet 250 mg 335 Ferron
1 Cravit Tetes Mata 336 Ferron
1 Allegysal Tetes Mata 2% 5 ml 337 Ferron
1 Ketricin Tablet 338 Ferron
Ketricin Gel 339 Ferron
2 Histrin Syrup 340 Ferron
5 Medixon Injeksi 125 mg 341 Ferron
Medixon tablet 4mg 342 Ferron
Medixon tablet 16mg 343 Ferron
1 Sodium Bicarbonat Generik Tablet 500 mg 344 G
1 Borraginol - S Suppos 345 G
1 Metoclorpramide Generik Tablet 10 mg 346 G
Metoclorpramide Generik Injeksi 10mg/2ml 347 G
1 Dimenhidrinate Generik Tablet 348 G
1 Clonidine Generik Tablet 75/150 mcg 349 G
1 Furosemid Generik Tablet 40 mg 350 Kimia Farma
1 HCT Generik Tablet 25 mg 351 Kimia Farma
1 Spironolactone Generik Tablet 100 mg 352 Dexa Medica
3 Nor epineprin generik Injeksi 4 mg 353 G
1 Gemfibrozil Generik Tablet 300 mg 354 G
1 Efedrin HCl Generik Tablet 25 mg 355 G
Injeksi 50 mg/ml 356 G
1 Glyceril Guaiacolat Generik Tablet 357 G
1 Diazepam generik Tablet 5mg 358 G
Diazepam generik Tablet 10mg 359 G
1 Clobazam Generik Tablet 10mg 360 Dexa Medica
1 Phenobarbital Generik Tablet 30 mg 361 G
1 Phenitoin Generik Capsul 100 mg 362 G
Phenitoin Generik Injeksi 100 mg/2 ml 363 G

121
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

1 Carbamazepin Generik Tablet 200 mg 364 G


1 Tramadol Generik Capsul 50 mg 365 G
Injeksi 50 mg/ml 366 G
1 Paracetamol Generik Tablet 500 mg 367 PIM
Paracetamol Generik Syrup 120 mg/ 5 ml, 60 ml 368 ERITA
Paracetamol Generik Drop 100 mg/ml, 15 ml 369 G
1 Gentamycin Generik Injeksi 370 G
1 Cefalexin Generik Capsul 500 mg 371 G
1 Cefuroxim Generik Capsul 372 G
1 Cefotaxim Generik Injeksi 1gr 373 G
1 Ceftazidime Generik Injeksi 1gr 374 G
1 Cefepime Generik Injeksi 375 G
1 Ampicillin Generik Syrup 376 G
Ampicillin Generik Injeksi 377 G
1 Thiamfenicol Generik Capsul 500mg 378 G
1 Chlorampenicol Generik Capsul 379 G
Syrup 380 G
1 Erytromicin Generik Capsul 381 G
Erytromicin Generik Syrup 382 G
1 Claritromycin Generik Tablet 250 mg 383 G
1 Azithromycin Generik Tablet 384 G
1 Ofloxacin Generik Tablet 400mg 385 G
1 Tetracycline Generik Capsul 250mg 386 G
Tetracycline Generik Capsul 500mg 387 G
1 Doxyciclin Generik Capsul 100mg 388 G
1 Cotrimoxazole Generik Syrup 200/40 mg 389 G
Cotrimoxazole Generik Tablet 400/80 mg 390 G
1 Lincomycin Generik Capsul 391 G
1 Griseofulvin Generik Tablet 500mg 392 G
1 Ketokonazole Generik Tablet 200 mg 393 G
1 Fluconazole Generik Capsul 100 mg 394 G
1 Pyrantel Generik Tablet 125 mg 395 G
2 Artesunate Generik Injeksi 396 G
1 Metronidazole Generik Tablet 500 mg 397 G
Metronidazole Generik Infus 1 gr 398 G
1 PTU Generik Tablet 50 mg 399 G
PTU Generik Tablet 100mg 400 G
1 Vitamin B1 Generik Tablet 50mg 401 G
2 Vitamin B6 Generik Tablet 10 mg 402 G
3 Vitamin B12 Generik Tablet 403 G
1 Vitamin B comp Generik Tablet 404 G
2 Calsium Gluconas Generik Injeksi 405 G
3 Calsium Laktat Generik Tablet 406 G
1 Oxytetracyclin Generik Eye Oint 1% 3.5 gr 407 G
1 Chloramfenicol Generik Eye Oint 408 G
Chloramfenicol Generik Tetes Mata 409 G
1 Gentamycin Generik Salep Mata 410 G
1 Chloramfenicol Generik Salep 411 G
2 Gentamycin Generik Cream 0,1% 412 G
1 Oxytetracyxlin Generik Salep 413 G
1 Betamethasone Generik Cream 414 G
1 Hydrocortison Generik Cream 415 G
1 Miconazole Generik Cream 416 G
1 Acyclovir Generik Cream 417 G
1 Cetirizine Generik Tablet 418 G
1 CTM Generik Tablet 419 G
1 Dexametasone Generik Tablet 0.5 mg 420 G
1 Prednison GeneriK Tablet 5 mg 421 G
1 Metil Prednisolon GeneriK Tablet 422 G
1 Laxadine Syrup 423 Gelenium
3 Laxarec Supp 424 Gelenuim
1 Truvada Tablet 300/200 mg 425 Gilead
1 Viread Tablet 300 mg 426 Gillead
1 Arixtra Injeksi 2.5 mg 427 Glaxo
1 Seretide Spray Inhaler 125 mcg 428 Glaxo
1 Seretide Discus Inhaler 500 mcg 429 Glaxo
1 Ventolin Inhaler 430 Glaxo

122
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

1 Flixotide Nebuls 431 Glaxo


2 Zyloric Tablet 100mg 432 Glaxo
4 Fortum Injeksi 1gr 433 Glaxo
3 Abbotic XL Caplet 500mg 434 Glaxo
4 Abbotic Syrup 435 Glaxo
1 Valtrex Tablet 500 mg 436 Glaxo
1 3TC-HBV Tablet 100 mg 437 Glaxo
1 Retrovir Capsul 100 mg 438 Glaxo
1 Harnal D Tablet 439 Glaxo
1 Bactroban Salep 2% 10gr 440 Glaxo
2 Proliva Kaplet 441 Gracia
4 Gracef Injeksi 1 gr 442 Gracia
4 Nerva plus Tablet 443 Gracia
1 Thyrax Tablet 50 mcg 444 Granon
1 Ibuprofen Generik Tablet 400 mg 445 Great
1 For Asma Tablet 2.5 mg 446 Guardian
3 Nudep Capsul 50 mg 447 Guardian
1 Goflex Tablet 500 mg 448 Guardian
5 Govazole Capsul 150 mg 449 Guardian
2 Estiva-600 Tablet 600 mg 450 Hetero - India
1 Lansoprazole Generik Capsul 30 mg 451 Hexapharm
1 Ketorolac Generik Injeksi 10 mg, 30 mg 452 Hexapharm
1 Allopurinol Generik Tablet 100 mg 453 Hexapharm
Allopurinol Generik Tablet 300 mg 454 Hexapharm
1 Sefpirom Generik Injeksi 1 gr 455 Hexapharm
1 Ranitidin Generik Injeksi 456 Hexpharm
Ranitidin Generik Tablet 150 mg 457 Hexpharm
1 Pantoprazol Generik Capsul 458 Hexpharm
1 Propanolol Generik Tablet 10 mg 459 Hexpharm
Propanolol Generik Tablet 20 mg 460 Hexpharm
1 Losartan Generik Tablet 50 mg 461 Hexpharm
1 Citicholine Generik Tablet 500 mg 462 Hexpharm
Citicholine Generik Injeksi 250 mg 463 Hexpharm
Citicholine Generik Injeksi 500 mg 464 Hexpharm
1 Asam mefenamat Generik Tablet 500 mg 465 Hexpharm
1 Cefixim Generik Syrup 100mg 466 Hexpharm
Cefixim Generik Syrup 200mg 467 Hexpharm
Cefixim Generik Tablet 200 mg 468 Hexpharm
1 Metformin HCl Generik Tablet 500 mg 469 Hexpharm
Metformin HCl Generik Tablet 750 mg 470 Hexpharm
Amoxycillin Generik Syrup 471 Holi
1 Lactulax Syrup 200 ml 472 Ikapharm
3 Renoguard Capsul 473 Ikapharmindo
1 Digoxin Generik Tablet 0.25 mg 474 Indofarma
3 Vermic Syrup 360 mg/5 ml 475 Indofarma
2 Urispas Capsul 200mg 476 Indofarma
1 Acitral Syrup 477 Interbat
Acitral Tablet 478 Interbat
3 Gastridin Injeksi 150 mg 479 Interbat
Gastridin Tablet 150 mg 480 Interbat
3 Protop Capsul 20 mg 481 Interbat
4 Interlac Drop 482 Interbat
2 Gitas plus injeksi 483 Interbat
Gitas plus Tablet 484 Interbat
3 Invomit Tablet 4 mg 485 Interbat
Invomit Tablet 8 mg 486 Interbat
Invomit Injeksi 4mg/2ml 487 Interbat
3 Intervask Tablet 5 mg 488 Interbat
Intervask Tablet 10 mg 489 Interbat
1 Interpril Tablet 5 mg 490 Interbat
Interpril Tablet 10 mg 491 Interbat
2 Insaar Tablet 50 mg 492 Interbat
3 Incelin Tablet 500 mg 493 Interbat
Incelin Injeksi 250 mg 494 Interbat
Incelin Injeksi 500 mg 495 Interbat
Incelin Injeksi 1000 mg 496 Interbat
3 Internic Injeksi 250 mg 497 Interbat

123
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

3 Clogin Tablet 75 mg 498 Interbat


2 Theobron Syrup 499 Interbat
3 Interpect Tablet 30 mg 500 Interbat
Interpect Eliksir 501 Interbat
2 Trifed Tablet 502 Interbat
Trifed Syrup 503 Interbat
1 Alco Drop 504 Interbat
1 Alco syrup 505 Interbat
2 Tradyl tablet 50 mg 506 Interbat
Injeksi 50 mg/ml 507 Interbat
5 Pamol Syrup 120 mg/5 ml, 60 ml 508 Interbat
Pamol Drop 125 mg, 250 mg 509 Interbat
Pamol Supp 510 Interbat
3 Mefinter Tablet 250 mg, 500 mg 511 Interbat
4 Ketrobat injeksi 30 mg, 10 mg 512 interbat
5 Diflam tablet 50 mg 513 Interbat
4 Meloxin Injeksi 10 mg /ml 514 Interbat
4 Ceptik Capsul 100mg 515 Interbat
Ceptik Syrup 100 mg/ 5ml 516 Interbat
2 Starxon Injeksi 1 gr 517 Interbat
5 Rycef Injeksi 1 gr 518 Interbat
3 Intermoxil Tablet 500mg 519 Interbat
Intermoxil Tablet 1000mg 520 Interbat
5 Clabat Syrup, Tablet 500mg tab 521 Interbat
1 Timipen Injeksi 1gr 522 Interbat
4 Thiamycin Capsul 523 Interbat
Syrup 524 Interbat
2 Erythrin Syrup 525 Interbat
7 Zycin Tablet 500 mg 526 Interbat
3 Spiranter Tablet 500mg 527 Interbat
3 Interflox Tablet 500mg 528 Interbat
2 Tetrin Capsul 500 mg 529 Interbat
2 Interzol Cream 530 Interbat
1 Urinter Capsul 400mg 531 Interbat
1 Renax Tablet 532 Interbat
2 Prestrenol Tablet 533 Interbat
1 Inkurin Tablet 250 mg 534 Interbat
2 Neurobat Forte Injeksi 535 Interbat
5 Ossovit Tablet 536 Interbat
16 Inlacta DHA Capsul 537 Interbat
5 Inbion Capsul 538 Interbat
1 Aviter Sachet 539 Interbat
1 Otopain Tetes Telinga 540 Interbat
2 Inerson Cream 541 Interbat
3 Interzol Cream 542 Interbat
2 Zoter Cream 543 Interbat
1 Sanoskin Melladerm Plus Tule Pack 544 Interbat
1 Sanoskin Foam Pack 545 Interbat
1 Sanoskin Melladerm Plus Gell Plus 546 Interbat
1 Sanoskin Oxy Gell 30 gr 547 Interbat
5 Intrizin Tablet 548 Interbat
Intrizin drop 549 Interbat
2 Cortamine Syrup 550 Interbat
2 Indexon Injeksi 0.5 mg 551 Interbat
1 Stugeron Tablet 25 mg 552 Jannson
3 Motilium Tablet 10 mg 553 Jansen
2 Ultracet Tablet 554 Janssen
3 Analtram tablet 555 Janssen
1 Vermox 500 Tablet 500 mg 556 Janssen
1 Fucohelix Tablet 100 mg 557 Kalbe Farma
5 Rantin Injeksi 150 mg 558 Kalbe Farma
Rantin Tablet 559 Kalbe Farma
4 Lancid Capsul 30 mg 560 Kalbe Farma
3 Pranza Injeksi 561 Kalbe Farma
2 Invitec Tablet 562 Kalbe Farma
3 Liprolac Sachet 563 Kalbe Farma
2 Urdahex Capsul 564 Kalbe Farma

124
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

Urdahex Syrup 565 Kalbe Farma


3 Hepamax Kaplet 566 Kalbe Farma
1 Forheva Injeksi 567 Kalbe Farma
1 Venosmil Gel 60 gr 568 Kalbe Farma
2 Captensin Tablet 12,5. mg 569 Kalbe Farma
Captensin Tablet 25 mg 570 Kalbe Farma
Captensin Tablet 50 mg 571 Kalbe Farma
2 Irvask Tablet 150 mg 572 Kalbe Farma
2 Braint act Tablet 500 mg 573 Kalbe Farma
Braint act Sachet 1000 mg 574 Kalbe Farma
Braint act Injeksi 500 mg 575 Kalbe Farma
3 Truvas Tablet 10mg 576 Kalbe Farma
1 Kalnex Tablet 250 mg 577 Kalbe Farma
Kalnex Tablet 500 mg 578 Kalbe Farma
Kalnex Injeksi 250 mg 579 Kalbe Farma
Kalnex Injeksi 500 mg 580 Kalbe Farma
2 Vestein Syrup 175 mg/5 ml 581 Kalbe Farma
Vestein Capsul 300 mg 582 Kalbe Farma
1 Fexofed Tablet 583 Kalbe Farma
4 Zypraz Tablet 0.5 mg 584 Kalbe Farma
2 Serlof Tablet 50 mg 585 Kalbe Farma
1 Kalxetin Capsul 10 mg 586 Kalbe Farma
Kalxetin Capsul 20 mg 587 Kalbe Farma
2 Provelyn Tablet 75 mg 588 Kalbe Farma
1 Ibufenz Syrup 100 mg/5ml, 60 ml 589 Kalbe Farma
2 Torasic Tablet 10 mg 590 Kalbe Farma
1 Kaltrofen Suppos 100 mg 591 Kalbe Farma
Kaltrofen Injeksi 100 mg / 2ml 592 Kalbe Farma
1 Neuralgin RX Tablet 500 mg 593 Kalbe Farma
2 Frego Tablet 5 mg 594 Kalbe Farma
Frego Tablet 10 mg 595 Kalbe Farma
3 Neurotam Capsul 800 mg 596 Kalbe Farma
Neurotam Injeksi 1 gr/5 ml 597 Kalbe Farma
1 Mediflex Krim 598 Kalbe Farma
1 Endroline Injeksi 3.75 mg 599 Kalbe Farma
2 Mikasin Injeksi 500mg/2ml 600 Kalbe Farma
3 Cefspan Capsul 200mg 601 Kalbe Farma
Cefspan Syrup 100 mg/ 5 ml 602 Kalbe Farma
6 Broadced Injeksi 1 gr 603 Kalbe Farma
2 Cefizox Injeksi 1 gr 604 Kalbe Farma
1 Bactesyn Tablet 375mg 605 Kalbe Farma
Bactesyn Injeksi 750mg 606 Kalbe Farma
Bactesyn Injeksi 1500mg 607 Kalbe Farma
2 Merofen Injeksi 1 gr 608 Kalbe Farma
2 Cravit Tablet 500 mg 609 Kalbe Farma
Cravit Infus 500 mg 610 Kalbe Farma
3 Climadan Capsul 300 mg 611 Kalbe Farma
4 Flucoral Capsul 50 mg 612 Kalbe Farma
3 Neo Gynoxa Vag. Tablet 613 Kalbe Farma
1 Nephrolit Capsul 614 Kalbe Farma
1 Induxin Injeksi 615 Kalbe Farma
4 Premaston Tablet 5mg 616 Kalbe Farma
4 Nocid Capsul 617 Kalbe Farma
5 Metrix Tablet 3mg 618 Kalbe Farma
5 Osfit DHA Tablet 619 Kalbe Farma
8 Vomilat Tablet 620 Kalbe Farma
3 Cernevit Injeksi 621 Kalbe Farma
5 Zink Care Tablet eff 622 Kalbe Farma
13 Zegavit Tablet 623 Kalbe Farma
18 Likurmin Syrup 624 Kalbe Farma
10 Emineton Tablet 625 Kalbe Farma
1 Peptisol Box/Pack 626 Kalbe Farma
2 Diabetasol Box/Pack 627 Kalbe Farma
3 Nephrisol Box/Pack 628 Kalbe Farma
2 Trolit Sachet 629 Kalbe Farma
3 Glisodin Capsul 630 Kalbe Farma
1 Tarivid Tetes Mata 631 Kalbe Farma

125
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

3 Kemicetine Salep Mata 1% 5 gr 632 Kalbe Farma


Kemicetine Tetes Mata 0,5% 5 ml 633 Kalbe Farma
1 Clarastill Tetes Mata 634 Kalbe Farma
1 Cationorm Tetes Mata 635 Kalbe Farma
2 Tarivid Otic Tetes Telinga 636 Kalbe Farma
1 Bioplacenton Gel 637 Kalbe Farma
2 Kalmicetin Cream 638 Kalbe Farma
2 Mycoral Cream 639 Kalbe Farma
1 Climadan Acne Cream 15 gr 640 Kalbe Farma
4 Cetinal Syrup 641 Kalbe Farma
4 Hexilon Tablet 8mg 642 Kalbe Farma
2 Octalbin 20% Infus 50ml 643 Kalbe Farma
Octalbin 20% Infus 100ml 644 Kalbe Farma
4 Albumin Human 20% Infus 100ml 645 Kima Farma
2 Enzymfort Tablet 646 Kimia Farma
1 Pankreoflat Tablet 647 Kimia Farma
1 Anti hemoroid Generik Suppos 648 kimia farma
1 Dopamin Giulini Injeksi 649 Kimia Farma
1 Isosorbidedinitrate Generik Tablet 10 mg 650 kimia farma
1 Amlodipine Generik Tablet 5 mg 651 Kimia Farma
Amlodipine Generik Tablet 10 mg 652 Kimia Farma
1 Menadione Tablet 10 mg 653 Kimia Farma
Menadione Injeksi 10 mg 654 Kimia Farma
1 Salbutamol Generik Tablet 2 mg 655 Kimia Farma
Salbutamol Generik Tablet 4 mg 656 Kimia Farma
1 Ambroxol Generik Tablet 30 mg 657 Kimia Farma
1 Dextrometrophan Generik Tablet 15 mg 658 Kimia Farma
Dextrometrophan Generik Syrup 60 ml 659 Kimia Farma
1 Codein Tablet 30 mg 660 Kimia Farma
2 Codipront Tablet 30 mg 661 Kimia Farma
Codipront Syrup 662 Kimia Farma
1 Codipront Cum Expect. Tablet 663 Kimia Farma
Codipront Cum Expect. Syrup 664 Kimia Farma
2 Neurodial Tablet 665 Kimia Farma
1 Coditam Tablet 666 Kimia Farma
7 Cefaxon Injeksi 1 gr 667 Kimia Farma
1 Acyclovir Generik Tablet 200 mg 668 Kimia Farma
Acyclovir Generik Tablet 400 mg 669 Kimia Farma
2 Hiviral Tablet 150 mg 670 Kimia Farma
1 Duviral Tablet 300 mg/ 150 mg 671 Kimia Farma
1 Neviral Tablet 200 mg 672 Kimia Farma
1 Staviral Tablet 30 mg 673 Kimia Farma
1 Chloroquin Generik Tablet 250 mg 674 Kimia Farma
1 Kina Generik Tablet 500 mg 675 Kimia Farma
1 Primet Tablet 25 mg 676 Kimia Farma
2 Batugin Eliksir 677 Kimia Farma
1 Duvadilan Injeksi 678 Kimia Farma
1 Glibenclamid Generik Tablet 679 Kimia Farma
1 Vitamin A Tablet 20000IU 680 Kimia Farma
Vitamin A Tablet 50000IU 681 Kimia Farma
1 Vitamin C Generik Tablet 50 mg 682 Kimia Farma
1 Neurovit E Tablet 683 Kimia Farma
3 Dasabion Capsul 684 Kimia Farma
1 Oralit Sachet 685 Kimia Farma
3 Betadine Kumur 190 ml 686 Kimia farma
1 Scabicid Cream 687 Kimia Farma
1 Salep 2-4 Salep 688 Kimia Farma
3 Iodin Povidone Solution 30ml 689 Kimia Farma
Iodin Povidone Solution 60ml 690 Kimia Farma
4 Rivanol Solution 60ml 691 Kimia Farma
1 Lesichol Capsul 300 mg 692 Landson
Lesichol Capsul 600 mg 693 Landson
2 Carsive Injeksi 10 mg / 10 ml 694 Landson
4 Lancolin Tablet 500 mg 695 Landson
Lancolin Tablet 250 mg 696 Landson
Lancolin Injeksi 500 mg 697 Landson
1 Plasmin Capsul 250 mg 698 Landson

126
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

1 Flavin Tablet 699 Landson


3 Lexa Tablet 500 mg 700 Landson
Lexa Infus 500 mg 701 Landson
2 Lanturol Capsul 702 Landson
9 Provital Plus Capsul 703 Landson
1 Diadium Tablet 2 mg 704 Lapi
2 Ciflon Kaplet 705 Lapi
1 Natto-10 Tablet 706 Lapi
2 Lasal Syrup 2 mg / 5 ml 707 LAPI
3 Lapisiv Syrup 708 Lapi
1 Lapifed DM Syrup 709 Lapi
1 Analtram Tablet 710 Lapi
2 Latropil Syrup 500 gr/5ml 711 Lapi
2 Labipal Capsul 500 mcg 712 Lapi
Labipal Injeksi 500 mcg 713 Lapi
2 Cefila Drop 150 mg /5 ml 714 Lapi
3 Cefxon Injeksi 715 Lapi
3 Lacedim Injeksi 1gr 716 Lapi
3 Merotik Injeksi 0,5 gr 717 Lapi
3 Lacophen Suspensi 718 Lapi
4 Cravox Tablet 500 mg 719 Lapi
Cravox Infus 500 mg 720 Lapi
5 Clinmas Capsul 300mg 721 Lapi
2 Itzol Tablet 100 mg 722 Lapi
1 Apyalis Drop 723 Lapi
9 Nonemi Tablet 724 Lapi
1 Imunos Tablet 725 Lapi
2 Lameson Tablet 4mg 726 Lapi
Lameson Tablet 8mg 727 Lapi
2 Betadine Solution 60ml 728 Mahakam
Betadine Salep 729 Mahakam
1 Efavirenz Tablet 600 mg 730 Matrix - India
3 Tenofovir Generik Tablet 300 mg 731 Matrix - India
3 Thrombo Aspilet Tablet 732 Medifarma
7 Sumagesic Tablet 600 mg 733 Medifarma
1 Kanamycin Meiji Injeksi 1 gr 734 Meiji
Kanamycin Meiji Injeksi 2gr 735 Meiji
1 Phosmycin Injeksi 500 mg 736 Meiji
1 Streptomycin Sulphat Injeksi 1 gr 737 Meiji
1 Meiact Tablet 200 mg 738 Meiji
1 Procain Penicillin G Injeksi 3.000.000 IU 739 Meiji
1 Dibekacin Tetes Mata 740 Meiji
4 Mucos Drop 20 ml 741 Meprofarm
Mucos Syrup 60 mg 742 Meprofarm
1 Deptral Tablet 50 mg 743 Meprofarm
6 Pyrexin Syrup 120 mg/5 ml, 60 ml 744 Meprofarm
1 Norages Injeksi 500 mg/ml 745 Meprofarm
3 Proneuron Tablet 746 Meprofarm
1 Myores Tablet 2 mg 747 Meprofarm
4 Promuba Syrup 125 mg/5 ml 748 Meprofarm
6 Folaplus Tablet 749 Meprofarm
6 Maltiron Capsul 750 Meprofarm
6 Sirplus Syrup 751 Meprofarm
2 Concor Tablet 5 mg 752 Merck
3 Maintate Tablet 5 mg 753 Merck
2 Dolofenac Na Tablet 754 Merck
1 Neurofenac Plus Tablet 50 mg 755 Merck
1 Encephabol Tablet 100 mg 756 Merck
Encephabol Syrup 100 ml 757 Merck
1 Azol Tablet 200 mg 758 Merck
1 Luthenyl Kaplet 759 Merck
2 Glucophage Tablet 500 mg 760 Merck
1 Glucovance Tablet 1.25/250 761 Merck
Glucovance Tablet 2.5/500 762 Merck
Glucovance Tablet 5/500 763 Merck
2 Euthyrax Tablet 50 mcg 764 Merck
1 Thyrozol Tablet 5mg 765 Merck

127
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

Thyrozol Tablet 10mg 766 Merck


3 Neurobion Tablet 1000 mg 767 Merck
Neurobion Tablet 5000 mg 768 Merck
Neurobion Injeksi 5000 mg 769 Merck
5 Neurosanbe Tablet 1000 mg 770 Merck
Neurosanbe Tablet 5000 771 Merck
6 Becombion Syrup 110 ml 772 Merck
4 Hemobion Tablet 773 Merck
2 KSR Tablet 600 mg 774 Merck
1 Biocream Cream 775 Merck
2 Mersivas Tablet 10 mg 776 Mersi
1 Simucil Capsul 200 mg 777 Mersifarma
3 Kutoin Injeksi 100 mg/2 ml 778 Mersifarma
2 Heximer Tablet 2 mg 779 Mersifarma
7 Mersibion Injeksi 5000 mg 780 Mersifarma
3 Kandistatin Drop 781 Metiska
1 Metilat Tablet 782 Metiska Farma
1 Tribestan Tablet 250mg 783 Metiska Farma
3 Molafat Susp 60 cc 784 Molex Ayus
1 Molagit Tablet 600 mg 785 Molex ayus
2 Molapect Syrup 15mg/5ml 786 Molex ayus
Molapect Tablet 30 mg 787 Molex ayus
2 OBH Generik Syrup 788 Molex ayus
4 Dextral Tablet 789 Molex Ayus
Dextral Syrup 790 Molex Ayus
1 Alpara Tablet 791 Molex Ayus
Alpara Syrup 792 Molex Ayus
1 Antalgin Generik/Lexagin Tablet 500 mg 793 Molex Ayus
3 Gentalex cream Cream 794 Molex Ayus
1 Vytorin Tablet 10/10 mg 795 MSD
1 Arcoxia Kaplet 60 mg 796 MSD
Arcoxia Kaplet 90 mg 797 MSD
Arcoxia Kaplet 120 mg 798 MSD
1 Januvia Tablet 50 mg 799 MSD
Januvia Tablet 100 mg 800 MSD
1 Janumet Tablet 50mg / 500mg 801 MSD
1 Artem Injeksi 80 mg/ ml 802 Multimitra
2 Tenofovir Generik Tablet 300 mg 803 Mylan - India
1 Piptal Drop 804 Nicholas
1 Neo Mercazol Tablet 5mg 805 Nicholas
1 Polycrol Forte Syrup 806 Nicolas
4 Ranicare sirup 807 Nicolas
1 Exforge Tablet 5/80 mg 808 Novartis
Exforge Tablet 5/160 mg 809 Novartis
1 Co-Diovan Tablet 80/12.5 mg 810 Novartis
1 Anafranil Tablet 25 mg 811 Novartis
2 Tegretol Tablet 100 mg 812 Novartis
Tegretol Tablet CR 200 mg 813 Novartis
1 Ritalin Tablet 10 mg 814 Novartis
3 Voltaren Tablet SR 75 mg 815 Novartis
Voltaren Tablet Retard 100 mg 816 Novartis
Voltaren Gel 1% 20 gr 817 Novartis
1 Cataflam D Tablet 50 mg 818 Novartis
2 Cataflam Drop Drop 819 Novartis
3 Cataflam Fast Sachet 50 mg 820 Novartis
1 Sebivo Tablet 600 mg 821 Novartis
1 Fenistil Drop 822 Novartis
Fenistil Syrup 823 Novartis
2 Novepide Tablet 100 mg 824 Novell
3 Noprostol Tablet Vagina 825 Novell
1 Lacto B Sachet 826 Novell
1 Livapro SS Capsul 827 Novell
4 Bisovell Tablet 5 mg 828 Novell
1 Ataroc Syrup 25 mcg 829 Novell
1 Piracetam Generik Capsul 800 mg 830 Novell
Piracetam Generik Injeksi 1 gr 831 Novell

128
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

Piracetam Generik Injeksi 3 gr 832 Novell


Piracetam Generik Infus 12 gr/60 ml 833 Novell
1 Zotic Kaplet 30 mg 834 Novell
1 Sefoperazon Generik Injeksi 1 gr 835 Novell
1 Ceftizoxime Na Generik Injeksi 836 Novell
Fluconazole Generik Infus 100 mg 837 Novell
2 Isprinol Tablet 838 Novell
Syrup 839 Novell
5 Prorenal Capsul 840 Novell
7 Vitamam Tablet 1, 2, 3 841 Novell
4 OreZinc Sachet 842 Novell
14 Zamel Syrup 843 Novell
17 Prolacta DHA Capsul 844 Novell
1 Lactamam Tablet 845 Novell
1 Meropenem Generik Injeksi 0,5 gr 846 Novell
Meropenem Generik Injeksi 1 gr 847 Novell
1 Actrapid HM 100 Vial 100 iu/ml 10 ml 848 Novonordisk
1 Novorapid Penfill Injeksi 849 Novonordisk
1 Novomix Penfill Penfill 850 Novonordisk
1 Levemir Penfill Penfill 851 Novonordisk
3 Yosenob Tablet 300 mg 852 Nufarindo
1 Ichtiyol-Zalf Tube 10% 15 gr 853 Nufarindo
1 Collacure Pack 854 Nufarindo
1 Omeprazole Generik Capsul 20 mg 855 nulab
1 Domperidone Generik Tablet 10 mg 856 Nulab
Ondansentron Generik Tablet 4 mg 857 Nulab
Ondansentron Generik Tablet 8 mg 858 Nulab
1 Nurest Capsul 350 mg 859 Nulab
1 Meloxicam Generik Tablet 7,5mg 860 Nulab
Meloxicam Generik Tablet 15mg 861 Nulab
1 Mecobalamin Generik Injeksi 500 mcg 862 Nulab
1 Glimepiride Generik Tablet 1mg 863 Nulab
Glimepiride Generik Tablet 2 mg 864 Nulab
1 Rejuvit Capsul 865 Nutrindo
1 Unigen Capsul 866 Nutrindo
1 Dalfarol Capsul 100IU 867 Nutrindo
Dalfarol Capsul 400IU 868 Nutrindo
1 Lynoral Tablet 869 Organon
2 Piton-S Injeksi 870 Organon
1 Pletaal Tablet 100mg 871 Otsuka
2 Meptin Tablet 50 mcg 872 Otsuka
3 Meptin swing heler Spray 10 mcg/dosis 873 Otsuka
4 Magtral Susp 874 Otto
Magtral Tablet 875 Otto
2 Musin Susp 120 cc 876 Otto
4 Rocer Capsul 20 mg 877 Otto
1 Scopamin Plus Tablet 878 Otto
4 Piralen Injeksi 10 mg/2 ml 879 Otto
2 Transamin Injeksi 250 mg 880 Otto
Transamin Injeksi 500 mg 881 Otto
Transamin Tablet 250 mg 882 Otto
Transamin Tablet 500 mg 883 Otto
1 Tilsan Tablet 25 mg 884 Otto
2 Valeptik Tablet 250 mg 885 Otto
3 Ottopan Drop 100 mg/ml 886 Otto
1 Tramifen Tablet 887 Otto
2 Dansera Tablet 888 Otto
2 Biolincom Capsul 500 mg 889 Otto
Biolincom Syrup 250 mg /5 ml 890 Otto
1 Viajoy Capsul 50 mg 891 Otto
1 Hi-Bone Tablet 892 Otto
2 Visebad Drop 893 Otto
6 Prednicort Injeksi 125 mg/ml 894 Otto
1 Dextamine Tablet 895 Papros
1 Olmetec Tablet 896 Pfizer
1 Caduet Tablet 897 Pfizer

129
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

1 Lipitor Tablet 10mg 898 Pfizer


Lipitor Tablet 20mg 899 Pfizer
3 Xanax Tablet 0.5mg 900 Pfizer
Xanax Tablet 1mg 901 Pfizer
2 Dilantin Tablet 100mg 902 Pfizer
1 Lyrica Tablet 75mg 903 Pfizer
1 Neurontin Capsul 300mg 904 Pfizer
2 Feldene Tablet 10 mg 905 Pfizer
Feldene Tablet 20 mg 906 Pfizer
1 Celebrex Capsul 200mg 907 Pfizer
1 Provera Tablet 10mg 908 Pfizer
5 Zithromax Tablet 909 Pfizer
Zithromax Syrup 910 Pfizer
3 Diflucan Capsul 50 mg 911 Pfizer
2 Kolkatriol Capsul 912 Phapros
1 Sulfas Ferosus Generik Tablet 913 Phapros
4 Pharolit Sachet 914 Phapros
1 Microlax Suppos 5 mg 915 Pharos
Microlax Suppos 10 mg 916 Pharos
2 Ascardia Tablet 80mg 917 Pharos
Ascardia Tablet 160mg 918 Pharos
1 Euphyllin R Tablet 250 mg 919 Pharos
2 Euphyllin Retard Mite Tablet 125 mg 920 Pharos
5 Proris Suspensi 200 mg/ 5 ml 921 Pharos
Proris Supp 125 mg 922 Pharos
3 Clinovir Tablet 200 mg 923 Pharos
1 Albothyl Ovula Vag. Tablet 924 Pharos
3 Solcoseryl Gel 5 gr 925 Pharos
2 Albothyl Solution 926 Pharos
1 Nebacetin Salep 927 Pharos
Nebacetin powder 928 Pharos
2 Fibramed Tablet 300 mg 929 Promed
2 Profamed Tablet 500mg 930 Promed
2 Prolecin Tablet 400mg 931 Promed
2 Biodasin Capsul 300mg 932 Promed
4 Neuromed Tablet 5000 mg 933 Promed
3 Cituroxim Kaplet 500 mg 934 Puspa
Cituroxim Injeksi 1000 mg 935 Puspa
3 Vitamin K injeksi 936 Rajawali
4 Valium Tablet 5 mg 937 Roche
Valium Injeksi 10 mg/ 2 ml 938 Roche
1 Lexotan Tablet 1.5mg 939 Roche
Lexotan Tablet 3mg 940 Roche
1 Dormicum Injeksi 5 mg/5 ml 941 Roche
1 Fansidar Tablet 500 mg/25 mg 942 Roche
1 Xenical Capsul 120 mg 943 Roche
5 Vip Albumin Capsul 944 Royal Medicine
5 Pumpitor Injeksi 20 mg 945 Sanbe
3 Braxidin Tablet 946 Sanbe
4 Vosedon Syrup 947 Sanbe
1 Proxime Tablet 948 Sanbe
3 Astharol Syrup 949 Sanbe
2 Mucohexin Tablet 8 mg 950 Sanbe
Mucohexin Eliksir 120 ml 951 Sanbe
2 Sanadryl Syrup 952 Sanbe
1 Aldisa SR Capsul 953 Sanbe
1 Tremenza Tablet 954 Sanbe
Tremenza Syrup 955 Sanbe
2 Valisanbe Tablet 5 mg 956 Sanbe
4 Sanmol Tablet 500 mg 957 Sanbe
Sanmol Syrup 120 mg/5 ml, 60 ml 958 Sanbe
Sanmol Drop 959 Sanbe
Sanmol Infus 1000 mg 960 Sanbe
3 Bufect Forte Syrup 100 mg/5ml, 60 ml 961 Sanbe
4 Bufect Syrup 962 Sanbe
2 Mefinal Tablet 250 mg, 500 mg 963 Sanbe
3 Megabal Capsul 500 mcg 964 sanbe

130
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

2 Regumen Tablet 5mg 965 Sanbe


1 Blesifen Tablet 50mg 966 Sanbe
2 Sagestam Injeksi 967 Sanbe
4 Glybotic Injeksi 250 mg 968 Sanbe
Glybotic Injeksi 500 mg 969 Sanbe
2 Cefat Syrup 125 mg/ 5 ml 970 Sanbe
Cefat Capsul 500 mg 971 Sanbe
3 Cefat F Syrup 250 mg/ 5 ml 972 Sanbe
6 Sporetik Syrup 100 mg/ 5 ml 973 Sanbe
8 Terfacef Injeksi 1 gr 974 Sanbe
2 Taxegram Injeksi 1gr 975 Sanbe
2 Zidifect Injeksi 1gr 976 Sanbe
2 Amoxsan Tablet 977 Sanbe
Amoxsan Syrup 978 Sanbe
Amoxsan Drop 979 Sanbe
Amoxsan Injeksi 980 Sanbe
2 Claneksi Tablet, Syrup 981 Sanbe
4 Claneksi F Syrup 982 Sanbe
3 Cinam Injeksi 1500mg 983 Sanbe
4 Merosan Injeksi 0,5 gr 984 Sanbe
Merosan Injeksi 1 gr 985 Sanbe
2 Pelastin Injeksi 1gr 986 Sanbe
2 Biothicol Capsul 987 Sanbe
2 Colsancetine Injeksi 1gr 988 Sanbe
3 Erysanbe Capsul 250mg 989 Sanbe
Erysanbe Capsul 500mg 990 Sanbe
Erysanbe Syrup 991 Sanbe
2 Bicrolid Tablet 250mg 992 Sanbe
2 Mezatrim Tablet 200mg 993 Sanbe
4 Spirasin Tablet 500mg 994 Sanbe
2 Baquinor F Tablet 995 Sanbe
Baquinor F Infus 996 Sanbe
2 Siclidon Capsul 100mg 997 Sanbe
2 Sanprima Syrup 200/40 mg 998 Sanbe
Sanprima Tablet 400/80 mg 999 Sanbe
3 Sanprima F Tablet 800/160 mg 1000 Sanbe
4 Prolic Capsul 150mg 1001 Sanbe
Prolic Capsul 300mg 1002 Sanbe
3 Nolipo Capsul 500mg 1003 Sanbe
2 Nymico Drop 1004 Sanbe
5 Trichodazole Infus 1 gr 1005 Sanbe
1 Trichodazole Plus Ovula Vag. Tablet 1006 Sanbe
3 Urotraktin Capsul 400mg 1007 Sanbe
3 Preabor Tablet 5mg 1008 Sanbe
2 Sansulin N Cartridge 100 iu/ml 3 ml 1009 Sanbe
4 Forbetes Tablet 500 mg 1010 Sanbe
D. ASAM FOLAT 1 Folavit Tablet 1011 Sanbe
2 Sanbe Plex Drop 1012 Sanbe
1 Elkana Syrup 1013 Sanbe
10 Becom C Tablet 1014 Sanbe
11 Becom Zet Tablet 1015 Sanbe
1 Berry vision Tablet 1016 Sanbe
Berry vision tablet disp 1017 Sanbe
2 Biosanbe Tablet 1018 Sanbe
1 Flamar Tetes Mata 1019 SANBE
1 Sanbe Tears Tetes Mata 1020 Sanbe
1 Akilen Tetes Telinga 1021 Sanbe
2 Otilon Tetes Telinga 1022 Sanbe
1 Forumen Tetes Telinga 1023 Sanbe
2 Pibaksin Salep 2% 10gr 1024 Sanbe
1 Cinolon Cream 1025 Sanbe
1 Cinolon - N Cream 1026 Sanbe
1 Alloris Syrup 10 mg 1027 SANBE
2 Acran Injeksi 150 mg 1028 Sanbe
2 Lesifit Capsul 1029 Sandoz
2 Atorsan Tablet 10mg 1030 Sandoz
Atorsan Tablet 20mg 1031 Sandoz

131
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

5 Urica Tablet 100mg 1032 Sandoz


Urica Tablet 300mg 1033 Sandoz
2 Tonar Kaplet 1034 Sandoz
1 Lovenox Injeksi 0.2, cc 1035 Sanofi
Lovenox Injeksi 0.4, cc 1036 Sanofi
Lovenox Injeksi 0.6 cc 1037 Sanofi
1 Lactasid Dewasa Solution 1038 Sanofi
2 Lactasid Bayi 1039 Sanofi
1 Ultraproct N Suppos 1040 Schering
Ultraproct N Salep 1041 Schering
1 Andriol Kapsul 40 mg 1042 Schering
1 Cerazette Tablet 75 mcg 1043 Schering
1 Diane Tablet 1044 Schering
1 Exluton Limas Tablet 0,5 mg 1045 Schering
2 Triquilar ED Tablet 1046 Schering
1 Engelic Tablet 1047 Schering
1 Cyclofem Injeksi 1048 Schering
1 Garamycin Cream 0,1% 1049 Schering
1 Elocon Cream 1050 Schering
1 Lotriderm Cream 1051 Schering
1 Claritin Tablet 1052 Schering
1 Celestamine Tablet 1053 Schering
Celestamine Syrup 1054 Schering
1 Parasol Cream 20 gr 1055 SDM
1 Ardium HD Tablet 500 mg 1056 Servier
1 Bioprexum Tablet 5 mg 1057 Servier
1 Coveram Tablet 5/5 mg 1058 Servier
Coveram Tablet 5/10 mg 1059 Servier
1 Stablon Tablet 12.5 mg 1060 Servier
1 Arcalion Tablet 200 mg 1061 Servier
1 Diamicron MR Tablet 30mg 1062 Servier
Diamicron MR Tablet 60 mg 1063 Servier
1 Proliver Tablet 1064 Simex
1 GCM Kaplet 1065 Simex
2 GCM Forte Kaplet 1066 Simex
15 Sim DHA Syrup 1067 Simex
1 Apecur Syrup 100 ml 1068 Simex
1 Imunvit plus Tablet 1069 Simex
3 Simdrol Tablet 4mg 1070 Simex
2 Fucoidan 100 Tablet 100 mg 1071 Soho
2 Biocurliv Tablet 1072 Soho
4 Cedantron Injeksi 1073 Soho
1 Memoran Capsul 100 mg 1074 Soho
1 Coldizo Tablet isap 1075 Soho
3 Ketopain Injeksi 30 mg/ml 1076 Soho
1 Evalin Injeksi 1 gr 1077 Soho
2 Sochlor Syrup 500 mg 1078 Soho
2 Valvir Tablet 500 mg 1079 Soho
2 Curvit Kaplet 1080 Soho
3 Curvit CL Emulsion Syrup 175 ml 1081 Soho
4 Asthin Bond Capsul 1082 Soho
1 Imboost Force Capsul 1083 Soho
Imboost Force Syrup 1084 Soho
1 Tantum verde Kumur 120 ml 1085 Soho
1 Ativan Tablet 1mg 1086 Sunti S
Ativan Tablet 2mg 1087 Sunti S
1 Mediklin TR Cream 15 gr 1088 Suryaderm
2 Kenalog Cream 1089 Taisho
1 Borraginol - N Suppos 1090 Takeda
2 Blopress Tablet 8mg 1091 Takeda
Blopress Tablet 16 mg 1092 Takeda
1 Nonflamin Capsul 1093 Takeda
1 Ceradolan Tablet 1094 Takeda
1 Kedacillin Injeksi 1 gr 1095 Takeda
1 Actos Tablet 30mg 1096 Takeda
1 Alinamin F Tablet 1097 Takeda

132
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

Injeksi 1098 Takeda


2 Herbesser Injeksi 1099 Tanabe
3 Herbesser CD Tablet 100 mg 1100 Tanabe
Herbesser CD Tablet 200 mg 1101 Tanabe
1 Tanapres Tablet 10 mg 1102 Tanabe
1 Adona AC Injeksi 25 mg 1103 Tanabe
Adona AC Injeksi 50 mg 1104 Tanabe
Adona AC Tablet 10 mg 1105 Tanabe
1 Aspar K Tablet 300 mg 1106 Tanabe
1 Buscopan Tablet 10 mg 1107 Tempo
Buscopan injeksi 1108 Tempo
2 Myori Tablet 1109 Tempo
1 Glutrop Tablet 1000 mg 1110 Tropica Mas
2 Lipitrob Tablet 600 mg 1111 Tropicamas
1 Thrombophob Gel 20 gr 1112 Tunggal I.A
1 Aspilet Tablet 80 mg 1113 UAP
2 Yazon Injeksi 1 gr 1114 Yarindo
1 Fluimucil Eff Tablet 600 mg 1115 Zambon
1 Spedifen Tablet 400 mg 1116 Zambon
1 Otozambon Tetes Telinga 1117 Zambon
1 Hidonac Infus 200mg/ml 1118 Zambon
Theobron Caps
Salbutamol Generik Syrup
Ambroxol Generik Syrup 60 ml
J. OBAT ANTI PARKINSON
1 THP Generik Tablet 2 mg

Feldene Gel

1 Estero Tablet 0.625 mg

1 Cefachlor Generik Capsul 500 mg


1 Spiramycin Generik Tablet

1 FDC Tablet Dispersi 30


FDC Tablet Dispersi 50
FDC Tablet Dispersi 60

1 Triomun Junior Tablet Dispersi 12 mg


Triomun Junior Tablet Dispersi 60 mg
Triomun Junior Tablet Dispersi 100mg

N. ANTI CACING
2 Combantrin Tablet 125 mg
Combantrin Tablet 250 mg
Combantrin Syrup 360 mg/5 ml

2 Lactasid Vag Gel


2 Amadiab Tablet 1mg
3 Folamil genio Capsul

F. KALSIUM
1 Calnic Syrup

Vitaplex Drop

2 Eye bright Tablet


3 Eyevit Syrup

4 Vitanorm Tablet

1 Retivit Tablet

Imunos Syrup
1 Natacen Tetes Mata

133
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Komposisi / Zat aktif No. Nama Obat Kemasan Kandungan NO Farmasi

B. ANTISEPTIK MATA DENGAN KORTIKOSTEROID


2 Cendo Tobroson MD TM Mini Dose
Cendo Xytrol Tetes Mata 5 ml

1 Glaucon Tablet

1 Lubricent Salep Mata

1 Rephitel Salep Mata

I. PREPARAT MATA GOL. LAIN

2 Cendo Catarlent
1 Sanorin Kumur

1 Ketoconazole Generik

1 Myco Z Cream

D. ANTIVIRUS TOPIKAL

E. ANTIINFEKSI TOPIKAL DENGAN KORTIKOSTEROID


2 Desolex - N Cream
G. ANTIHISTAMIN/ANTIPRURITUS TOPIKAL
1 Caladin Lotion
2 Caladril Powder

1 Asam salisilat Solution 3%

1 PK Powder 5 gr

1 Marcaine

Dexametasone Generik Injeksi 0.5 mg

134
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

135
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

136
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

107,500
1,063,500 50
90,500 100
284,350 30
135,000
62,000
92,000
78,750
120,450
175,450
273,000
193,500

97,650
98,438
47,615

137
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

138
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

139
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

2 box 100,700 100

1 box 90,682 100

140
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

10,000 100
3,300 1

141
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

142
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

143
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

144
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

145
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

146
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

147
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

148
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

149
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

150
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

spendifen

151
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

152
Jumlah
Kemasan @HARGA ISIAN HARGA
Awal

153
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


1 Fluimucil Eff Tablet 600 mg Zambon
2 Nitrisol Box/Pack Fahrenheit
3 Peptisol Box/Pack Kalbe Farma
4 Diabetasol Box/Pack Kalbe Farma
5 Nephrisol Box/Pack Kalbe Farma
6 Renalyte Cairan 200 mg Fahrenheit
7 Renalyte Cairan 500 ml Fahrenheit
1 Aminefron Caplet Dexa Medica
2 Abbotic XL Caplet 500mg Glaxo
3 Theobron Caps
4 Longatin Capsul Alpharma
5 Inhipraz Capsul 30 mg Bernofarm
6 Cefadroxil Generik Capsul 500mg Bernofarm
7 Cefabiotic Capsul 500 mg Bernofarm
8 Zistic Capsul 500mg Bernofarm
9 Natavit Capsul Bernofarm
10 Pradaxa Capsul 75 mg Boehringer
11 Pradaxa Capsul 150 mg Boehringer
12 Mucotein Capsul 300 mg Combiphar
13 Comsikla Capsul Combiphar
14 Budenofalk Capsul 3 mg Darya Varia
15 Lacidofil Capsul Dexa Medica
16 Rhinos SR Capsul Dexa Medica
17 Dexacef F Capsul Dexa Medica
18 Methycobalt Capsul 250 mcg Eisai
19 Ximesco Capsul 200mg Escolab
20 Cethixim Capsul 500mg Ethica
21 Prazotec Capsul Fahrenheit
22 Edotin Capsul 300 mg Ferron
23 Sporacid Capsul 100 mg Ferron
24 Phenitoin Generik Capsul 100 mg G
25 Tramadol Generik Capsul 50 mg G
26 Cefalexin Generik Capsul 500 mg G
27 Cefuroxim Generik Capsul G
28 Thiamfenicol Generik Capsul 500mg G
29 Chlorampenicol Generik Capsul G
30 Erytromicin Generik Capsul G
31 Tetracycline Generik Capsul 250mg G
32 Tetracycline Generik Capsul 500mg G
33 Doxyciclin Generik Capsul 100mg G
34 Lincomycin Generik Capsul G
35 Fluconazole Generik Capsul 100 mg G
36 Retrovir Capsul 100 mg Glaxo
37 Nudep Capsul 50 mg Guardian
38 Govazole Capsul 150 mg Guardian
39 Lansoprazole Generik Capsul 30 mg Hexapharm
40 Pantoprazol Generik Capsul Hexpharm
41 Renoguard Capsul Ikapharmindo
42 Urispas Capsul 200mg Indofarma
43 Protop Capsul 20 mg Interbat
44 Ceptik Capsul 100mg Interbat
45 Thiamycin Capsul Interbat
46 Tetrin Capsul 500 mg Interbat
47 Urinter Capsul 400mg Interbat
48 Inlacta DHA Capsul Interbat
49 Inbion Capsul Interbat
50 Lancid Capsul 30 mg Kalbe Farma
51 Urdahex Capsul Kalbe Farma
52 Vestein Capsul 300 mg Kalbe Farma
53 Kalxetin Capsul 10 mg Kalbe Farma
54 Kalxetin Capsul 20 mg Kalbe Farma
55 Neurotam Capsul 800 mg Kalbe Farma
56 Cefspan Capsul 200mg Kalbe Farma
57 Flucoral Capsul 50 mg Kalbe Farma
58 Nephrolit Capsul Kalbe Farma
59 Nocid Capsul Kalbe Farma
60 Glisodin Capsul Kalbe Farma
61 Dasabion Capsul Kimia Farma

154
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


62 Lesichol Capsul 300 mg Landson
63 Lesichol Capsul 600 mg Landson
64 Plasmin Capsul 250 mg Landson
65 Lanturol Capsul Landson
66 Provital Plus Capsul Landson
67 Labipal Capsul 500 mcg Lapi
68 Clinmas Capsul 300mg Lapi
69 Maltiron Capsul Meprofarm
70 Simucil Capsul 200 mg Mersifarma
71 Livapro SS Capsul Novell
72 Piracetam Generik Capsul 800 mg Novell
73 Prorenal Capsul Novell
74 Prolacta DHA Capsul Novell
75 Omeprazole Generik Capsul 20 mg nulab
76 Nurest Capsul 350 mg Nulab
77 Rejuvit Capsul Nutrindo
78 Unigen Capsul Nutrindo
79 Dalfarol Capsul 100IU Nutrindo
80 Dalfarol Capsul 400IU Nutrindo
81 Rocer Capsul 20 mg Otto
82 Biolincom Capsul 500 mg Otto
83 Viajoy Capsul 50 mg Otto
84 Neurontin Capsul 300mg Pfizer
85 Celebrex Capsul 200mg Pfizer
86 Diflucan Capsul 50 mg Pfizer
87 Kolkatriol Capsul Phapros
88 Biodasin Capsul 300mg Promed
89 Xenical Capsul 120 mg Roche
90 Vip Albumin Capsul Royal Medicine
91 Aldisa SR Capsul Sanbe
92 Megabal Capsul 500 mcg sanbe
93 Cefat Capsul 500 mg Sanbe
94 Biothicol Capsul Sanbe
95 Erysanbe Capsul 250mg Sanbe
96 Erysanbe Capsul 500mg Sanbe
97 Siclidon Capsul 100mg Sanbe
98 Prolic Capsul 150mg Sanbe
99 Prolic Capsul 300mg Sanbe
100 Nolipo Capsul 500mg Sanbe
101 Urotraktin Capsul 400mg Sanbe
102 Lesifit Capsul Sandoz
103 Memoran Capsul 100 mg Soho
104 Asthin Bond Capsul Soho
105 Imboost Force Capsul Soho
106 Nonflamin Capsul Takeda
107 Cefachlor Generik Capsul 500 mg
108 Folamil genio Capsul
109 Comsporin Capsul 200 mg Combiphar
110 Clindamycin OGB Capsul 150mg Dexa Medica
111 Clindamycin OGB Capsul 300mg Dexa Medica
112 Piroxicam Generik Capsul 10 mg Esa Indo
113 Piroxicam Generik Capsul 20 mg Esa Indo
114 Climadan Capsul 300 mg Kalbe Farma
115 Ostriol Capsul Lunak 0,25 mcg Fahrenheit
Humalog Mix 25 Cartridge Eli Lily
Sansulin N Cartridge 100 iu/ml 3 ml Sanbe
1 Decubal Cream 20 gr Actavis
2 Apolar Cream Alpharma
3 Apolar N Cream Alpharma
4 Kamillosan Cream Asta Medica
5 Esperson Cream Aventis
6 Daktarin Diapers Cream Bayer
7 Motaderm Cream Bernofarm
8 Fusycom Cream Combiphar
9 Mebo Cream 20 gr Combiphar
10 Burnazin Cream Darya Varia
11 Virtaz Cream Fahrenheit

155
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


12 Gentamycin Generik Cream 0,1% G
13 Betamethasone Generik Cream G
14 Hydrocortison Generik Cream G
15 Miconazole Generik Cream G
16 Acyclovir Generik Cream G
17 Interzol Cream Interbat
18 Inerson Cream Interbat
19 Interzol Cream Interbat
20 Zoter Cream Interbat
21 Kalmicetin Cream Kalbe Farma
22 Mycoral Cream Kalbe Farma
23 Climadan Acne Cream 15 gr Kalbe Farma
24 Scabicid Cream Kimia Farma
25 Biocream Cream Merck
26 Gentalex cream Cream Molex Ayus
27 Cinolon Cream Sanbe
28 Cinolon - N Cream Sanbe
29 Garamycin Cream 0,1% Schering
30 Elocon Cream Schering
31 Lotriderm Cream Schering
32 Parasol Cream 20 gr SDM
33 Mediklin TR Cream 15 gr Suryaderm
34 Kenalog Cream Taisho
35 Myco Z Cream
36 Desolex - N Cream
37 Nomesis Drop Bernofarm
38 Laxoberon Drop Boehringer
39 Vometa Drop Dexa Medica
40 Rhinos Neo Drop Dexa Medica
41 Renasistin Drop Fahrenheit
42 Fungatin Drop Ferron
43 Paracetamol Generik Drop 100 mg/ml, 15 ml G
44 Interlac Drop Interbat
45 Alco Drop Interbat
46 Pamol Drop 125 mg, 250 mg Interbat
47 Intrizin drop Interbat
48 Cefila Drop 150 mg /5 ml Lapi
49 Apyalis Drop Lapi
50 Mucos Drop 20 ml Meprofarm
51 Kandistatin Drop Metiska
52 Piptal Drop Nicholas
53 Cataflam Drop Drop Novartis
54 Fenistil Drop Novartis
55 Ottopan Drop 100 mg/ml Otto
56 Visebad Drop Otto
57 Sanmol Drop Sanbe
58 Amoxsan Drop Sanbe
59 Nymico Drop Sanbe
60 Sanbe Plex Drop Sanbe
61 Vitaplex Drop
1 Interpect Eliksir Interbat
2 Batugin Eliksir Kimia Farma
3 Mucohexin Eliksir 120 ml Sanbe
4 Oxytetracyclin Generik Eye Oint 1% 3.5 gr G
5 Chloramfenicol Generik Eye Oint G
6 Mederma Gel 20 gr Combiphar
7 Ketricin Gel Ferron
8 Venosmil Gel 60 gr Kalbe Farma
9 Bioplacenton Gel Kalbe Farma
10 Voltaren Gel 1% 20 gr Novartis
11 Solcoseryl Gel 5 gr Pharos
12 Thrombophob Gel 20 gr Tunggal I.A
13 Feldene Gel
14 Lactasid Vag Gel
15 Sanoskin Melladerm Plus Gell Plus Interbat
16 Sanoskin Oxy Gell 30 gr Interbat
17 Levofloxacin Generik Infus 500 mg Dexa
18 Fladex Infus 1 gr Dexa Medica

156
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


19 Human Albumin Behring 20% Infus 50ml Dexa Medica
20 Albuminar 25% Infus 100ml Dexa Medica
21 Plasbumin 5% Infus 250ml Dipa
22 Plasbumin 25% Infus 50ml Dipa
23 Plasbumin 25% Infus 100ml Dipa
24 Farlev Infus 750 mg Fahreinheit
25 Farmadol Infus 1000 mg Fahrenheit
26 Cryptal Infus 200 mg Fahrenheit
27 Fepiram Infus 12gr/60 m Ferron
28 Metronidazole Generik Infus 1 gr G
29 Cravit Infus 500 mg Kalbe Farma
30 Octalbin 20% Infus 50ml Kalbe Farma
31 Octalbin 20% Infus 100ml Kalbe Farma
32 Albumin Human 20% Infus 100ml Kima Farma
33 Lexa Infus 500 mg Landson
34 Cravox Infus 500 mg Lapi
35 Piracetam Generik Infus 12 gr/60 ml Novell
36 Fluconazole Generik Infus 100 mg Novell
37 Sanmol Infus 1000 mg Sanbe
38 Baquinor F Infus Sanbe
39 Trichodazole Infus 1 gr Sanbe
40 Hidonac Infus 200mg/ml Zambon
41 Seretide Spray Inhaler 125 mcg Glaxo
42 Seretide Discus Inhaler 500 mcg Glaxo
43 Ventolin Inhaler Glaxo
44 Symbicort Turbo Heler Inhaler 60 dosi 80/4.5 AstraZenica
45 Symbicort Turbo Heler Inhaler 60 dosi 160/4.5 AstraZenica
1 Stesolid Injeksi 10 mg Actavis
2 Chloramex Injeksi 500mg Actavis
3 Perdipine injeksi Injeksi 10 mg / 10 ml Astellas
4 Nexium Injeksi 40 mg AstraZeneca
5 Lasix Injeksi 20 mg / ml Aventis
6 Claforan Injeksi 1 gr Aventis
7 Nimotop Injeksi 10 mg/50 ml Bayer
8 Metolon Injeksi 10 mg/2 ml Berno
9 Omeprazole Generik Injeksi Bernofarm
10 Pantoprazol Generik Injeksi Bernofarm
11 Kliran Injeksi 4 mg Bernofarm
12 Kliran Injeksi 8 mg Bernofarm
13 Injeksi 30 mg/ml Bernofarm
14 Benocetam Injeksi 3 gr/15 ml Bernofarm
15 Simikan Injeksi 250 mg/2 ml Bernofarm
16 Macef Injeksi Bernofarm
17 Pycin Injeksi 1500mg Bernofarm
18 Catapres injeksi 150 mg Boehringer
19 Bisolvon Injeksi 2mg/ml Boehringer
20 Neo K Injeksi Combi
21 Hepa-Merz Injeksi Combiphar
22 Somatostatin Lyomark Injeksi 250 mcg/3 mg Combiphar
23 Phental Injeksi Combiphar
24 Tyason Injeksi 1 gr Combiphar
25 Combicef Injeksi 1gr Combiphar
26 Venofer Injeksi 100 mg Combiphar
27 Ozid Injeksi 20 mg Darya Varia
28 Kendaron Injeksi 150 mg / 3ml Darya Varia
29 Cedocard Injeksi 10 mg / 10 ml Darya Varia
30 Ondansentron Generik Injeksi 4 mg Dexa
31 Ondansentron Generik Injeksi 8 mg Dexa
32 Asam Tranxamat generik injeksi 250 mg Dexa
33 Asam Tranxamat generik injeksi 500 mg Dexa
34 Ceftriaxon Generik Injeksi 1 gr Dexa
35 Vomizol Injeksi Dexa Medica
36 SNMC Injeksi Dexa Medica
37 Somatostatin Eumedica Injeksi 250 mcg/3 mg Dexa Medica
38 Dobuject Injeksi 250 mg Dexa Medica
39 Raivas Injeksi 4 mg Dexa Medica
40 Streptase Injeksi 1.500.000 IU Dexa Medica
41 Pronalges Injeksi 100 mg / 2ml Dexa Medica

157
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


42 Amikasin Sulfat Generik Injeksi 250 mg/2 ml Dexa medica
43 Celocid Injeksi 750 mg Dexa Medica
44 Tizos Injeksi 1 gr Dexa Medica
45 Flamicort Injeksi Dexa Medica
46 Methycobalt Injeksi 500 mcg Eisai
47 Caprol Injeksi Ethica
48 Extrace Injeksi 500mg Ethica
49 Sotatic Injeksi 5 mg/ml, 2 ml Fahrenheit
50 Fargoxin Injeksi 0.5 mg/2 ml Fahrenheit
51 Farmabes Injeksi 5 mg/ml, 5 ml Fahrenheit
52 Farsix Injeksi 20 mg / ml Fahrenheit
53 Vascon Injeksi 4 mg Fahrenheit
54 Fendex Injeksi 50 mg/2 ml Fahrenheit
55 Rapime Injeksi Fahrenheit
56 Vancep Injeksi 500mg Fahrenheit
57 Crome Injeksi 50 mg Ferron
58 Ketesse Injeksi Ferron
59 Fepiram Injeksi 3gr/15ml Ferron
60 Ceftum Injeksi 0,5 gr Ferron
61 Ceftum Injeksi 1 gr Ferron
62 Medixon Injeksi 125 mg Ferron
63 Metoclorpramide Generik Injeksi 10mg/2ml G
64 Nor epineprin generik Injeksi 4 mg G
65 Injeksi 50 mg/ml G
66 Phenitoin Generik Injeksi 100 mg/2 ml G
67 Injeksi 50 mg/ml G
68 Gentamycin Generik Injeksi G
69 Cefotaxim Generik Injeksi 1gr G
70 Ceftazidime Generik Injeksi 1gr G
71 Cefepime Generik Injeksi G
72 Ampicillin Generik Injeksi G
73 Artesunate Generik Injeksi G
74 Calsium Gluconas Generik Injeksi G
75 Arixtra Injeksi 2.5 mg Glaxo
76 Fortum Injeksi 1gr Glaxo
77 Gracef Injeksi 1 gr Gracia
78 Ketorolac Generik Injeksi 10 mg, 30 mg Hexapharm
79 Sefpirom Generik Injeksi 1 gr Hexapharm
80 Ranitidin Generik Injeksi Hexpharm
81 Citicholine Generik Injeksi 250 mg Hexpharm
82 Citicholine Generik Injeksi 500 mg Hexpharm
83 Gastridin Injeksi 150 mg Interbat
84 Invomit Injeksi 4mg/2ml Interbat
85 Incelin Injeksi 250 mg Interbat
86 Incelin Injeksi 500 mg Interbat
87 Incelin Injeksi 1000 mg Interbat
88 Internic Injeksi 250 mg Interbat
89 Injeksi 50 mg/ml Interbat
90 Meloxin Injeksi 10 mg /ml Interbat
91 Starxon Injeksi 1 gr Interbat
92 Rycef Injeksi 1 gr Interbat
93 Timipen Injeksi 1gr Interbat
94 Neurobat Forte Injeksi Interbat
95 Indexon Injeksi 0.5 mg Interbat
96 Rantin Injeksi 150 mg Kalbe Farma
97 Pranza Injeksi Kalbe Farma
98 Forheva Injeksi Kalbe Farma
99 Braint act Injeksi 500 mg Kalbe Farma
100 Kalnex Injeksi 250 mg Kalbe Farma
101 Kalnex Injeksi 500 mg Kalbe Farma
102 Kaltrofen Injeksi 100 mg / 2ml Kalbe Farma
103 Neurotam Injeksi 1 gr/5 ml Kalbe Farma
104 Endroline Injeksi 3.75 mg Kalbe Farma
105 Mikasin Injeksi 500mg/2ml Kalbe Farma
106 Broadced Injeksi 1 gr Kalbe Farma
107 Cefizox Injeksi 1 gr Kalbe Farma
108 Bactesyn Injeksi 750mg Kalbe Farma
109 Bactesyn Injeksi 1500mg Kalbe Farma

158
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


110 Merofen Injeksi 1 gr Kalbe Farma
111 Induxin Injeksi Kalbe Farma
112 Cernevit Injeksi Kalbe Farma
113 Dopamin Giulini Injeksi Kimia Farma
114 Menadione Injeksi 10 mg Kimia Farma
115 Cefaxon Injeksi 1 gr Kimia Farma
116 Duvadilan Injeksi Kimia Farma
117 Carsive Injeksi 10 mg / 10 ml Landson
118 Lancolin Injeksi 500 mg Landson
119 Labipal Injeksi 500 mcg Lapi
120 Cefxon Injeksi Lapi
121 Lacedim Injeksi 1gr Lapi
122 Merotik Injeksi 0,5 gr Lapi
123 Kanamycin Meiji Injeksi 1 gr Meiji
124 Kanamycin Meiji Injeksi 2gr Meiji
125 Phosmycin Injeksi 500 mg Meiji
126 Streptomycin Sulphat Injeksi 1 gr Meiji
127 Procain Penicillin G Injeksi 3.000.000 IU Meiji
128 Norages Injeksi 500 mg/ml Meprofarm
129 Neurobion Injeksi 5000 mg Merck
130 Kutoin Injeksi 100 mg/2 ml Mersifarma
131 Mersibion Injeksi 5000 mg Mersifarma
132 Artem Injeksi 80 mg/ ml Multimitra
133 Piracetam Generik Injeksi 1 gr Novell
134 Piracetam Generik Injeksi 3 gr Novell
135 Sefoperazon Generik Injeksi 1 gr Novell
136 Ceftizoxime Na Generik Injeksi Novell
137 Meropenem Generik Injeksi 0,5 gr Novell
138 Meropenem Generik Injeksi 1 gr Novell
139 Novorapid Penfill Injeksi Novonordisk
140 Mecobalamin Generik Injeksi 500 mcg Nulab
141 Piton-S Injeksi Organon
142 Piralen Injeksi 10 mg/2 ml Otto
143 Transamin Injeksi 250 mg Otto
144 Transamin Injeksi 500 mg Otto
145 Prednicort Injeksi 125 mg/ml Otto
146 Cituroxim Injeksi 1000 mg Puspa
147 Vitamin K injeksi Rajawali
148 Valium Injeksi 10 mg/ 2 ml Roche
149 Dormicum Injeksi 5 mg/5 ml Roche
150 Pumpitor Injeksi 20 mg Sanbe
151 Sagestam Injeksi Sanbe
152 Glybotic Injeksi 250 mg Sanbe
153 Glybotic Injeksi 500 mg Sanbe
154 Terfacef Injeksi 1 gr Sanbe
155 Taxegram Injeksi 1gr Sanbe
156 Zidifect Injeksi 1gr Sanbe
157 Amoxsan Injeksi Sanbe
158 Cinam Injeksi 1500mg Sanbe
159 Merosan Injeksi 0,5 gr Sanbe
160 Merosan Injeksi 1 gr Sanbe
161 Pelastin Injeksi 1gr Sanbe
162 Colsancetine Injeksi 1gr Sanbe
163 Acran Injeksi 150 mg Sanbe
164 Lovenox Injeksi 0.2, cc Sanofi
165 Lovenox Injeksi 0.4, cc Sanofi
166 Lovenox Injeksi 0.6 cc Sanofi
167 Cyclofem Injeksi Schering
168 Cedantron Injeksi Soho
169 Ketopain Injeksi 30 mg/ml Soho
170 Evalin Injeksi 1 gr Soho
171 Kedacillin Injeksi 1 gr Takeda
172 Injeksi Takeda
173 Herbesser Injeksi Tanabe
174 Adona AC Injeksi 25 mg Tanabe
175 Adona AC Injeksi 50 mg Tanabe
176 Buscopan injeksi Tempo
177 Yazon Injeksi 1 gr Yarindo

159
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


178 Dexametasone Generik Injeksi 0.5 mg
179 Fluxum Injeksi 0,4 cc Fahrenheit
180 Fluxum Injeksi 0,6 cc Fahrenheit
181 Gitas plus injeksi Interbat
182 Ketrobat injeksi 30 mg, 10 mg interbat
1 Trolac Kaplet 10 mg Bernofarm
2 Seloxy Kaplet Ferron
3 Proliva Kaplet Gracia
4 Hepamax Kaplet Kalbe Farma
5 Ciflon Kaplet Lapi
6 Luthenyl Kaplet Merck
7 Arcoxia Kaplet 60 mg MSD
8 Arcoxia Kaplet 90 mg MSD
9 Arcoxia Kaplet 120 mg MSD
10 Zotic Kaplet 30 mg Novell
11 Cituroxim Kaplet 500 mg Puspa
12 Tonar Kaplet Sandoz
13 GCM Kaplet Simex
14 GCM Forte Kaplet Simex
15 Curvit Kaplet Soho
16 Nexium Kapsul 20 mg AstraZeneca
17 Nexium Kapsul 40 mg AstraZeneca
18 Fibrinase Kapsul Escolab
19 Andriol Kapsul 40 mg Schering
Mediflex Krim Kalbe Farma
1 Betadine Kumur 190 ml Kimia farma
2 Tantum verde Kumur 120 ml Soho
3 Sanorin Kumur
4 Caladin Lotion
5 LFX Mini Dose 0,6 ml Cendo
6 Cendo Polydex Mini Dose Cendo
7 Protagenta MD Mini Dose Cendo
8 Conver MD Mini Dose Cendo
9 Hyalub Mini Dose 5 mg Cendo
1 Pulmicort Nebulizer AstraZenica
2 Combivent Nebuls 0.5mg/2.5mg Boehringer
3 Farbivent Nebuls 0.5mg/2.5mg Fahrenheit
4 Flixotide Nebuls Glaxo
Adalat Oros 30 mg Bayer
1 Daryantull Pack Darya Varia
2 Sanoskin Melladerm Plus Tule Pack Interbat
3 Sanoskin Foam Pack Interbat
4 Collacure Pack Nufarindo
5 Novomix Penfill Penfill Novonordisk
6 Levemir Penfill Penfill Novonordisk
7 Nebacetin powder Pharos
8 Caladril Powder
9 PK Powder 5 gr
1 Kalitake Sachet 5 gr Dipa
2 Aviter Sachet Interbat
3 Liprolac Sachet Kalbe Farma
4 Braint act Sachet 1000 mg Kalbe Farma
5 Trolit Sachet Kalbe Farma
6 Oralit Sachet Kimia Farma
7 Cataflam Fast Sachet 50 mg Novartis
8 Lacto B Sachet Novell
9 OreZinc Sachet Novell
10 Pharolit Sachet Phapros
11 Hepa-Merz Sachet Granul Combiphar
12 Chloramfenicol Generik Salep G
13 Oxytetracyxlin Generik Salep G
14 Bactroban Salep 2% 10gr Glaxo
15 Salep 2-4 Salep Kimia Farma
16 Betadine Salep Mahakam
17 Nebacetin Salep Pharos
18 Pibaksin Salep 2% 10gr Sanbe
19 Ultraproct N Salep Schering

160
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


20 Cendo Genta Salep Mata CENDO
21 Cendo polygran Salep Mata Cendo
22 Cendo Hervis Salep Mata Cendo
23 Cendo Pipthalmic Salep Mata Cendo
24 Cendo Tobroson Salep Mata Cendo
25 Cendo Xytrol Salep Mata Cendo
26 Cendo Fenicol Salep Mata Cendo
27 Gentamycin Generik Salep Mata G
28 Kemicetine Salep Mata 1% 5 gr Kalbe Farma
29 Lubricent Salep Mata
30 Rephitel Salep Mata
31 Ranicare sirup Nicolas
32 Erefit Soft Capsul Escolab
33 Iodin Povidone Solution 30ml Kimia Farma
34 Iodin Povidone Solution 60ml Kimia Farma
35 Rivanol Solution 60ml Kimia Farma
36 Betadine Solution 60ml Mahakam
37 Albothyl Solution Pharos
38 Lactasid Dewasa Solution Sanofi
39 Asam salisilat Solution 3%
40 Meptin swing heler Spray 10 mcg/dosis Otsuka
41 Dumin Supp 125 mg Alpharma
42 Dumin Supp 250 mg Alpharma
43 Flagyl Forte Supp 1 gr Aventis
44 Pronalges Supp 100 mg Dexa Medica
45 Laxarec Supp Gelenuim
46 Pamol Supp Interbat
47 Proris Supp 125 mg Pharos
48 Dulcolax Suppos 5 mg Boehringer
49 Dulcolax Suppos 10 mg Boehringer
50 Borraginol - S Suppos G
51 Kaltrofen Suppos 100 mg Kalbe Farma
52 Anti hemoroid Generik Suppos kimia farma
53 Microlax Suppos 5 mg Pharos
54 Microlax Suppos 10 mg Pharos
55 Ultraproct N Suppos Schering
56 Borraginol - N Suppos Takeda
57 Stesolid Suppos 5mg Actavis
58 Stesolid Suppos 10mg Actavis
59 Ulsafat Susp 100 cc Combiphar
60 Ulsafat Susp 200 cc Combiphar
61 Impepsa Susp Fahrenheit
62 Magalat Susp Ferron
63 Molafat Susp 60 cc Molex Ayus
64 Magtral Susp Otto
65 Musin Susp 120 cc Otto
66 Lacophen Suspensi Lapi
67 Proris Suspensi 200 mg/ 5 ml Pharos
68 Depakene Syrup 250 mg/5 ml Abbot
69 Flagyl Forte Syrup 125 mg/5 ml Aventis
70 Domperidone Generik Syrup Bernofarm
71 Anafen Syrup 100 mg/5ml, 60 ml Bernofarm
72 Cefadroxil Generik Syrup Bernofarm
73 Cefabiotic Syrup 125 mg/5 ml Bernofarm
74 Tocef Syrup 100 mg/ 5 ml Bernofarm
75 Zistic Syrup Bernofarm
76 Natursif Syrup Bernofarm
77 Vitaplex Syrup Bernofarm
78 Dulcolactol Syrup Boehringer
79 Constipen Syrup 120 ml Combiphar
80 Mucotein DS Syrup 175mg/5 ml Combiphar
81 Comtusi Syrup 60 ml Combiphar
82 Zinc Pro Syrup Combiphar
83 Maltofer Syrup Combiphar
84 Comtro Syrup Combiphar
85 Levopront Syrup 60 ml Combipharm
86 Syrup Darya Varia
87 Vometa Syrup 60 ml Dexa Medica

161
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


88 Vectrin Syrup 175 mg/5 ml Dexa Medica
89 Rhinos Junior Syrup Dexa Medica
90 Dexacef F Syrup Dexa Medica
91 Azomax Syrup Dexa Medica
92 Divens Syrup 25 mg/5ml Dexa Medica
93 Colergis Syrup Dexa Medica
94 Antasida Generik Syrup 60 ml Erela
95 Histrin Syrup Ferron
96 Paracetamol Generik Syrup 120 mg/ 5 ml, 60 ml ERITA
97 Ampicillin Generik Syrup G
98 Syrup G
99 Erytromicin Generik Syrup G
100 Cotrimoxazole Generik Syrup 200/40 mg G
101 Laxadine Syrup Gelenium
102 Abbotic Syrup Glaxo
103 Cefixim Generik Syrup 100mg Hexpharm
104 Cefixim Generik Syrup 200mg Hexpharm
105 Amoxycillin Generik Syrup Holi
106 Lactulax Syrup 200 ml Ikapharm
107 Vermic Syrup 360 mg/5 ml Indofarma
108 Acitral Syrup Interbat
109 Theobron Syrup Interbat
110 Trifed Syrup Interbat
111 Alco syrup Interbat
112 Pamol Syrup 120 mg/5 ml, 60 ml Interbat
113 Ceptik Syrup 100 mg/ 5ml Interbat
114 Syrup Interbat
115 Erythrin Syrup Interbat
116 Cortamine Syrup Interbat
117 Urdahex Syrup Kalbe Farma
118 Vestein Syrup 175 mg/5 ml Kalbe Farma
119 Ibufenz Syrup 100 mg/5ml, 60 ml Kalbe Farma
120 Cefspan Syrup 100 mg/ 5 ml Kalbe Farma
121 Likurmin Syrup Kalbe Farma
122 Cetinal Syrup Kalbe Farma
123 Dextrometrophan Generik Syrup 60 ml Kimia Farma
124 Codipront Syrup Kimia Farma
125 Codipront Cum Expect. Syrup Kimia Farma
126 Lasal Syrup 2 mg / 5 ml LAPI
127 Lapisiv Syrup Lapi
128 Lapifed DM Syrup Lapi
129 Latropil Syrup 500 gr/5ml Lapi
130 Mucos Syrup 60 mg Meprofarm
131 Pyrexin Syrup 120 mg/5 ml, 60 ml Meprofarm
132 Promuba Syrup 125 mg/5 ml Meprofarm
133 Sirplus Syrup Meprofarm
134 Encephabol Syrup 100 ml Merck
135 Becombion Syrup 110 ml Merck
136 Molapect Syrup 15mg/5ml Molex ayus
137 OBH Generik Syrup Molex ayus
138 Dextral Syrup Molex Ayus
139 Alpara Syrup Molex Ayus
140 Polycrol Forte Syrup Nicolas
141 Fenistil Syrup Novartis
142 Ataroc Syrup 25 mcg Novell
143 Syrup Novell
144 Zamel Syrup Novell
145 Biolincom Syrup 250 mg /5 ml Otto
146 Zithromax Syrup Pfizer
147 Vosedon Syrup Sanbe
148 Astharol Syrup Sanbe
149 Sanadryl Syrup Sanbe
150 Tremenza Syrup Sanbe
151 Sanmol Syrup 120 mg/5 ml, 60 ml Sanbe
152 Bufect Forte Syrup 100 mg/5ml, 60 ml Sanbe
153 Bufect Syrup Sanbe
154 Cefat Syrup 125 mg/ 5 ml Sanbe
155 Cefat F Syrup 250 mg/ 5 ml Sanbe

162
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


156 Amoxsan Syrup Sanbe
157 Claneksi F Syrup Sanbe
158 Erysanbe Syrup Sanbe
159 Sanprima Syrup 200/40 mg Sanbe
160 Elkana Syrup Sanbe
161 Alloris Syrup 10 mg SANBE
162 Celestamine Syrup Schering
163 Sim DHA Syrup Simex
164 Apecur Syrup 100 ml Simex
165 Sochlor Syrup 500 mg Soho
166 Curvit CL Emulsion Syrup 175 ml Soho
167 Imboost Force Syrup Soho
168 Salbutamol Generik Syrup
169 Ambroxol Generik Syrup 60 ml
170 Combantrin Syrup 360 mg/5 ml
171 Calnic Syrup
172 Eyevit Syrup
173 Imunos Syrup
174 Sporetik Syrup 100 mg/ 5 ml Sanbe
175 Bronchophyllin Syrup 100 cc 150 mg/15 ml Darya Varia
176 Clabat Syrup, Tablet 500mg tab Interbat
1 Depakote ER Tablet 500 mg Abbot
2 Rhytmonorm Tablet 150 mg Abbott
3 Isoptin SR Tablet 240 mg Abbott
4 Aluvia Tablet 200 mg/ 50 mg Abbott
5 Dopamet Tablet 250 mg Actavis
6 Colistine Tablet 1.500.000 IU Actavis
7 Malarex Tablet 250 mg Actavis
8 Vesicare Tablet 5 mg Astellas
9 Crestor Tablet Astra
10 Kombiglyze XR Tablet 5/500 AstraZeneca
11 Lasix Tablet 40 mg Aventis
12 Amaryl Tablet 2mg Aventis
13 Cyclo-Progynova Tablet Bayer
14 Microlut Tablet 30 mcg Bayer
15 Mycroginon Tablet Bayer
16 Yasmin Tablet Bayer
17 Yaz Tablet Bayer
18 Angeliq Tablet Bayer
19 Andalan Tablet Bayer
20 Levitra Tablet 5 mg Bayer
21 Levitra Tablet 10 mg Bayer
22 Tablet Bayer
23 Antidia Tablet 2 mg Berno
24 Loperamid Generik Tablet Berno
25 Metolon Tablet 5 mg Berno
26 Metolon Tablet 10 mg Berno
27 Simvastatin Generik Tablet 10mg Berno
28 Simvastatin Generik Tablet 20mg Berno
29 Amoxycillin Generik Tablet 250mg Berno
30 Amoxycillin Generik Tablet 500mg Berno
31 Ciprofloxacin Generik Tablet 500 mg Berno
32 Sulcolon Tablet 500 mg Bernofarm
33 Lovask Tablet 10 mg Bernofarm
34 Asam Tranxamat generik Tablet 250 mg Bernofarm
35 Asam Tranxamat generik Tablet 500 mg Bernofarm
36 Neurogen Tablet 500 mg Bernofarm
37 Benoxuric Tablet 300mg Bernofarm
38 Ofertil Tablet 50mg Bernofarm
39 Glucoryl Tablet 2mg Bernofarm
40 Buscopan Plus Tablet Boehringer
41 Dulcolax Tablet Boehringer
42 Micardis Tablet 40 mg Boehringer
43 Twynsta Tablet 40/5 mg Boehringer
44 Catapres Tablet 75/150 mcg Boehringer
45 Bisolvon Tablet 4 mg Boehringer
46 Bisolvon Tablet 8 mg Boehringer

163
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


47 Glurenorm Tablet 30mg Boehringer
48 Videx Tablet 125 mg Bristol-Myers Sq
49 Librax Tablet Combiphar
50 Tanakan Tablet Combiphar
51 Lipanthyl Tablet 200mg Combiphar
52 X-Flam Tablet 50 mg Combiphar
53 Artrilox Tablet 15 mg Combiphar
54 Floxacom Tablet 500 mg Combiphar
55 Enzyplex Tablet Darya Varia
56 Urdafalk Tablet 250 mg Darya Varia
57 Cedocard Tablet 5 mg Darya Varia
58 Cedocard Tablet 10 mg Darya Varia
59 Lifezar Tablet 50 mg Darya Varia
60 Lifezar Tablet 100 mg Darya Varia
61 Profertil Tablet 50mg Darya Varia
62 Isoprinosin Tablet Darya Varia
63 Diltiazem Generik Tablet 30 mg Dexa
64 Diltiazem Generik Tablet 60 mg Dexa
65 Captopril Generik Tablet 12,5 mg Dexa
66 Captopril Generik Tablet 25 mg Dexa
67 Captopril Generik Tablet 50 mg Dexa
68 Ramipril generik Tablet 5 mg Dexa
69 Nifedipin Generik Tablet 10 mg Dexa
70 Clopidogrel Generik Tablet 75 mg Dexa
71 Spasmomen Tablet Dexa Medica
72 Vometa Tablet 10 mg Dexa Medica
73 Anvomer B6 Tablet Dexa Medica
74 Cordila SR Tablet 180 mg Dexa Medica
75 Tensivask Tablet 10 mg Dexa Medica
76 Nebilet Tablet 5 mg Dexa Medica
77 Candesartan Generik Tablet 8mg Dexa Medica
78 Candesartan Generik Tablet 16 mg Dexa Medica
79 Atorvastatin Generik Tablet 10 mg Dexa Medica
80 Stator Tablet 20mg Dexa Medica
81 Rhinofed Tablet Dexa Medica
82 Mertigo Tablet 8 mg Dexa Medica
83 Pondex Tablet 250 mg, 500 mg Dexa Medica
84 Pronalges Tablet 50 mg Dexa Medica
85 Pronalges Tablet 100 mg Dexa Medica
86 Pronalges CR Tablet 200 mg Dexa Medica
87 Degrium Tablet 5 mg Dexa Medica
88 Norelut Tablet 5mg Dexa Medica
89 Provula Tablet 50mg Dexa Medica
90 Co - Amoyclav Generik Tablet Dexa Medica
91 Dexyclav Tablet Dexa Medica
92 Azomax Tablet Dexa Medica
93 Hystolan Tablet Dexa Medica
94 Pregnolin Tablet 5mg Dexa Medica
95 Gliquidone Generik Tablet Dexa Medica
96 Galvusmet Tablet 50/500 Dexa Medica
97 Galvusmet Tablet 100/500 Dexa Medica
98 Lycoxy Tablet Dexa Medica
99 Laktafit Tablet Dexa Medica
100 Colergis Tablet Dexa Medica
101 Mucosta Tablet 100 mg Eisai
102 Aricept Tablet 5 mg Eisai
103 Merislon Tablet 12 mg EISAI
104 Myonal Tablet 50 mg Eisai
105 Antasida Generik Tablet Erela
106 Fetavita Tablet Escolab
107 Escovit Tablet Escolab
108 Imesco Tablet Escolab
109 Digezym Tablet Ethica
110 Ethiflox Tablet 200 mg Ethicha
111 Recolfar Tablet 0.5 mg Fahreinheit
112 Sysmuco Tablet 100 mg Fahrenheit
113 Gastrul Tablet Fahrenheit

164
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


114 Renagas Tablet Fahrenheit
115 Gasflat Tablet Fahrenheit
116 Sotatic Tablet 10 mg Fahrenheit
117 Fargoxin Tablet 0.25 mg Fahrenheit
118 Tiaryt Tablet 200 mg Fahrenheit
119 Farsorbid Tablet 5 mg Fahrenheit
120 Farsorbid Tablet 10 mg Fahrenheit
121 Farmabes Tablet Fahrenheit
122 Renacardon Tablet 5 mg Fahrenheit
123 Renacardon Tablet 10 mg Fahrenheit
124 Farnormin Tablet 50 mg Fahrenheit
125 Iretensa Tablet 150 mg Fahrenheit
126 Farsix Tablet 40 mg Fahrenheit
127 Carpiaton Tablet 100 mg Fahrenheit
128 Cartrilet Tablet 250 mg Fahrenheit
129 Pladogrel Tablet 75 mg Fahrenheit
130 Simarc-2 Tablet 2 mg Fahrenheit
131 Zolmia Tablet 10 mg Fahrenheit
132 Farmadol Tablet 500 mg Fahrenheit
133 Zifin Tablet Fahrenheit
134 Cryptal Tablet 50 mg Fahrenheit
135 Calos Tablet 500 mg Fahrenheit
136 Farmabex-C Tablet Fahrenheit
137 Renapar Tablet 10 mg Fahrenheit
138 Lactafar Tablet Fahrenheit
139 Falergi Tablet Fahrenheit
140 Hyperil 5 mg Tablet 5 mg Ferron
141 Crome Tablet 10 mg Ferron
142 Ganin Tablet 300mg Ferron
143 Mecox Tablet 15 mg Ferron
144 Ketesse Tablet Ferron
145 Glumin XR Tablet 500 mg Ferron
146 Glumin XR Tablet 750 mg Ferron
147 Glubose Tablet 50 mg Ferron
148 Oxypen Tablet Ferron
149 Biobran Tablet 250 mg Ferron
150 Ketricin Tablet Ferron
151 Medixon tablet 4mg Ferron
152 Medixon tablet 16mg Ferron
153 Sodium Bicarbonat Generik Tablet 500 mg G
154 Metoclorpramide Generik Tablet 10 mg G
155 Dimenhidrinate Generik Tablet G
156 Clonidine Generik Tablet 75/150 mcg G
157 Furosemid Generik Tablet 40 mg Kimia Farma
158 HCT Generik Tablet 25 mg Kimia Farma
159 Spironolactone Generik Tablet 100 mg Dexa Medica
160 Gemfibrozil Generik Tablet 300 mg G
161 Efedrin HCl Generik Tablet 25 mg G
162 Glyceril Guaiacolat Generik Tablet G
163 Diazepam generik Tablet 5mg G
164 Diazepam generik Tablet 10mg G
165 Clobazam Generik Tablet 10mg Dexa Medica
166 Phenobarbital Generik Tablet 30 mg G
167 Carbamazepin Generik Tablet 200 mg G
168 Paracetamol Generik Tablet 500 mg PIM
169 Claritromycin Generik Tablet 250 mg G
170 Azithromycin Generik Tablet G
171 Ofloxacin Generik Tablet 400mg G
172 Cotrimoxazole Generik Tablet 400/80 mg G
173 Griseofulvin Generik Tablet 500mg G
174 Ketokonazole Generik Tablet 200 mg G
175 Pyrantel Generik Tablet 125 mg G
176 Metronidazole Generik Tablet 500 mg G
177 PTU Generik Tablet 50 mg G
178 PTU Generik Tablet 100mg G
179 Vitamin B1 Generik Tablet 50mg G
180 Vitamin B6 Generik Tablet 10 mg G
181 Vitamin B12 Generik Tablet G

165
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


182 Vitamin B comp Generik Tablet G
183 Calsium Laktat Generik Tablet G
184 Cetirizine Generik Tablet G
185 CTM Generik Tablet G
186 Dexametasone Generik Tablet 0.5 mg G
187 Prednison GeneriK Tablet 5 mg G
188 Metil Prednisolon GeneriK Tablet G
189 Truvada Tablet 300/200 mg Gilead
190 Viread Tablet 300 mg Gillead
191 Valtrex Tablet 500 mg Glaxo
192 3TC-HBV Tablet 100 mg Glaxo
193 Harnal D Tablet Glaxo
194 Nerva plus Tablet Gracia
195 Thyrax Tablet 50 mcg Granon
196 Ibuprofen Generik Tablet 400 mg Great
197 For Asma Tablet 2.5 mg Guardian
198 Goflex Tablet 500 mg Guardian
199 Estiva-600 Tablet 600 mg Hetero - India
200 Ranitidin Generik Tablet 150 mg Hexpharm
201 Propanolol Generik Tablet 10 mg Hexpharm
202 Propanolol Generik Tablet 20 mg Hexpharm
203 Losartan Generik Tablet 50 mg Hexpharm
204 Citicholine Generik Tablet 500 mg Hexpharm
205 Asam mefenamat Generik Tablet 500 mg Hexpharm
206 Cefixim Generik Tablet 200 mg Hexpharm
207 Metformin HCl Generik Tablet 500 mg Hexpharm
208 Metformin HCl Generik Tablet 750 mg Hexpharm
209 Digoxin Generik Tablet 0.25 mg Indofarma
210 Acitral Tablet Interbat
211 Gastridin Tablet 150 mg Interbat
212 Gitas plus Tablet Interbat
213 Invomit Tablet 4 mg Interbat
214 Invomit Tablet 8 mg Interbat
215 Intervask Tablet 5 mg Interbat
216 Intervask Tablet 10 mg Interbat
217 Interpril Tablet 5 mg Interbat
218 Interpril Tablet 10 mg Interbat
219 Insaar Tablet 50 mg Interbat
220 Incelin Tablet 500 mg Interbat
221 Clogin Tablet 75 mg Interbat
222 Interpect Tablet 30 mg Interbat
223 Trifed Tablet Interbat
224 Tradyl tablet 50 mg Interbat
225 Mefinter Tablet 250 mg, 500 mg Interbat
226 Diflam tablet 50 mg Interbat
227 Intermoxil Tablet 500mg Interbat
228 Intermoxil Tablet 1000mg Interbat
229 Zycin Tablet 500 mg Interbat
230 Spiranter Tablet 500mg Interbat
231 Interflox Tablet 500mg Interbat
232 Renax Tablet Interbat
233 Prestrenol Tablet Interbat
234 Inkurin Tablet 250 mg Interbat
235 Ossovit Tablet Interbat
236 Intrizin Tablet Interbat
237 Stugeron Tablet 25 mg Jannson
238 Motilium Tablet 10 mg Jansen
239 Ultracet Tablet Janssen
240 Analtram tablet Janssen
241 Vermox 500 Tablet 500 mg Janssen
242 Fucohelix Tablet 100 mg Kalbe Farma
243 Rantin Tablet Kalbe Farma
244 Invitec Tablet Kalbe Farma
245 Captensin Tablet 12,5. mg Kalbe Farma
246 Captensin Tablet 25 mg Kalbe Farma
247 Captensin Tablet 50 mg Kalbe Farma
248 Irvask Tablet 150 mg Kalbe Farma
249 Braint act Tablet 500 mg Kalbe Farma

166
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


250 Truvas Tablet 10mg Kalbe Farma
251 Kalnex Tablet 250 mg Kalbe Farma
252 Kalnex Tablet 500 mg Kalbe Farma
253 Fexofed Tablet Kalbe Farma
254 Zypraz Tablet 0.5 mg Kalbe Farma
255 Serlof Tablet 50 mg Kalbe Farma
256 Provelyn Tablet 75 mg Kalbe Farma
257 Torasic Tablet 10 mg Kalbe Farma
258 Neuralgin RX Tablet 500 mg Kalbe Farma
259 Frego Tablet 5 mg Kalbe Farma
260 Frego Tablet 10 mg Kalbe Farma
261 Bactesyn Tablet 375mg Kalbe Farma
262 Cravit Tablet 500 mg Kalbe Farma
263 Premaston Tablet 5mg Kalbe Farma
264 Metrix Tablet 3mg Kalbe Farma
265 Osfit DHA Tablet Kalbe Farma
266 Vomilat Tablet Kalbe Farma
267 Zegavit Tablet Kalbe Farma
268 Emineton Tablet Kalbe Farma
269 Hexilon Tablet 8mg Kalbe Farma
270 Enzymfort Tablet Kimia Farma
271 Pankreoflat Tablet Kimia Farma
272 Isosorbidedinitrate Generik Tablet 10 mg kimia farma
273 Amlodipine Generik Tablet 5 mg Kimia Farma
274 Amlodipine Generik Tablet 10 mg Kimia Farma
275 Menadione Tablet 10 mg Kimia Farma
276 Salbutamol Generik Tablet 2 mg Kimia Farma
277 Salbutamol Generik Tablet 4 mg Kimia Farma
278 Ambroxol Generik Tablet 30 mg Kimia Farma
279 Dextrometrophan Generik Tablet 15 mg Kimia Farma
280 Codein Tablet 30 mg Kimia Farma
281 Codipront Tablet 30 mg Kimia Farma
282 Codipront Cum Expect. Tablet Kimia Farma
283 Neurodial Tablet Kimia Farma
284 Coditam Tablet Kimia Farma
285 Hiviral Tablet 150 mg Kimia Farma
286 Duviral Tablet 300 mg/ 150 mg Kimia Farma
287 Neviral Tablet 200 mg Kimia Farma
288 Staviral Tablet 30 mg Kimia Farma
289 Chloroquin Generik Tablet 250 mg Kimia Farma
290 Kina Generik Tablet 500 mg Kimia Farma
291 Primet Tablet 25 mg Kimia Farma
292 Glibenclamid Generik Tablet Kimia Farma
293 Vitamin A Tablet 20000IU Kimia Farma
294 Vitamin A Tablet 50000IU Kimia Farma
295 Vitamin C Generik Tablet 50 mg Kimia Farma
296 Neurovit E Tablet Kimia Farma
297 Lancolin Tablet 500 mg Landson
298 Lancolin Tablet 250 mg Landson
299 Flavin Tablet Landson
300 Lexa Tablet 500 mg Landson
301 Diadium Tablet 2 mg Lapi
302 Natto-10 Tablet Lapi
303 Analtram Tablet Lapi
304 Cravox Tablet 500 mg Lapi
305 Itzol Tablet 100 mg Lapi
306 Nonemi Tablet Lapi
307 Imunos Tablet Lapi
308 Lameson Tablet 4mg Lapi
309 Lameson Tablet 8mg Lapi
310 Efavirenz Tablet 600 mg Matrix - India
311 Tenofovir Generik Tablet 300 mg Matrix - India
312 Sumagesic Tablet 600 mg Medifarma
313 Meiact Tablet 200 mg Meiji
314 Deptral Tablet 50 mg Meprofarm
315 Proneuron Tablet Meprofarm
316 Myores Tablet 2 mg Meprofarm
317 Folaplus Tablet Meprofarm

167
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


318 Neurofenac Plus Tablet 50 mg Merck
319 Encephabol Tablet 100 mg Merck
320 Azol Tablet 200 mg Merck
321 Glucophage Tablet 500 mg Merck
322 Glucovance Tablet 1.25/250 Merck
323 Glucovance Tablet 2.5/500 Merck
324 Glucovance Tablet 5/500 Merck
325 Euthyrax Tablet 50 mcg Merck
326 Thyrozol Tablet 5mg Merck
327 Thyrozol Tablet 10mg Merck
328 Neurobion Tablet 1000 mg Merck
329 Neurobion Tablet 5000 mg Merck
330 Neurosanbe Tablet 1000 mg Merck
331 Neurosanbe Tablet 5000 Merck
332 Hemobion Tablet Merck
333 KSR Tablet 600 mg Merck
334 Mersivas Tablet 10 mg Mersi
335 Heximer Tablet 2 mg Mersifarma
336 Metilat Tablet Metiska Farma
337 Tribestan Tablet 250mg Metiska Farma
338 Molagit Tablet 600 mg Molex ayus
339 Molapect Tablet 30 mg Molex ayus
340 Dextral Tablet Molex Ayus
341 Alpara Tablet Molex Ayus
342 Antalgin Generik/Lexagin Tablet 500 mg Molex Ayus
343 Vytorin Tablet 10/10 mg MSD
344 Januvia Tablet 50 mg MSD
345 Januvia Tablet 100 mg MSD
346 Janumet Tablet 50mg / 500mg MSD
347 Tenofovir Generik Tablet 300 mg Mylan - India
348 Neo Mercazol Tablet 5mg Nicholas
349 Exforge Tablet 5/80 mg Novartis
350 Exforge Tablet 5/160 mg Novartis
351 Co-Diovan Tablet 80/12.5 mg Novartis
352 Anafranil Tablet 25 mg Novartis
353 Tegretol Tablet 100 mg Novartis
354 Ritalin Tablet 10 mg Novartis
355 Cataflam D Tablet 50 mg Novartis
356 Sebivo Tablet 600 mg Novartis
357 Novepide Tablet 100 mg Novell
358 Isprinol Tablet Novell
359 Vitamam Tablet 1, 2, 3 Novell
360 Lactamam Tablet Novell
361 Yosenob Tablet 300 mg Nufarindo
362 Domperidone Generik Tablet 10 mg Nulab
363 Ondansentron Generik Tablet 4 mg Nulab
364 Ondansentron Generik Tablet 8 mg Nulab
365 Meloxicam Generik Tablet 7,5mg Nulab
366 Meloxicam Generik Tablet 15mg Nulab
367 Glimepiride Generik Tablet 1mg Nulab
368 Glimepiride Generik Tablet 2 mg Nulab
369 Lynoral Tablet Organon
370 Meptin Tablet 50 mcg Otsuka
371 Magtral Tablet Otto
372 Scopamin Plus Tablet Otto
373 Transamin Tablet 250 mg Otto
374 Transamin Tablet 500 mg Otto
375 Tilsan Tablet 25 mg Otto
376 Valeptik Tablet 250 mg Otto
377 Tramifen Tablet Otto
378 Dansera Tablet Otto
379 Hi-Bone Tablet Otto
380 Dextamine Tablet Papros
381 Olmetec Tablet Pfizer
382 Caduet Tablet Pfizer
383 Lipitor Tablet 10mg Pfizer
384 Lipitor Tablet 20mg Pfizer

168
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


385 Dilantin Tablet 100mg Pfizer
386 Lyrica Tablet 75mg Pfizer
387 Feldene Tablet 10 mg Pfizer
388 Feldene Tablet 20 mg Pfizer
389 Provera Tablet 10mg Pfizer
390 Zithromax Tablet Pfizer
391 Sulfas Ferosus Generik Tablet Phapros
392 Euphyllin R Tablet 250 mg Pharos
393 Euphyllin Retard Mite Tablet 125 mg Pharos
394 Fibramed Tablet 300 mg Promed
395 Profamed Tablet 500mg Promed
396 Prolecin Tablet 400mg Promed
397 Valium Tablet 5 mg Roche
398 Lexotan Tablet 1.5mg Roche
399 Lexotan Tablet 3mg Roche
400 Fansidar Tablet 500 mg/25 mg Roche
401 Braxidin Tablet Sanbe
402 Proxime Tablet Sanbe
403 Mucohexin Tablet 8 mg Sanbe
404 Tremenza Tablet Sanbe
405 Valisanbe Tablet 5 mg Sanbe
406 Sanmol Tablet 500 mg Sanbe
407 Mefinal Tablet 250 mg, 500 mg Sanbe
408 Regumen Tablet 5mg Sanbe
409 Blesifen Tablet 50mg Sanbe
410 Amoxsan Tablet Sanbe
411 Bicrolid Tablet 250mg Sanbe
412 Mezatrim Tablet 200mg Sanbe
413 Spirasin Tablet 500mg Sanbe
414 Baquinor F Tablet Sanbe
415 Sanprima Tablet 400/80 mg Sanbe
416 Preabor Tablet 5mg Sanbe
417 Forbetes Tablet 500 mg Sanbe
418 Folavit Tablet Sanbe
419 Becom C Tablet Sanbe
420 Becom Zet Tablet Sanbe
421 Berry vision Tablet Sanbe
422 Biosanbe Tablet Sanbe
423 Atorsan Tablet 10mg Sandoz
424 Atorsan Tablet 20mg Sandoz
425 Urica Tablet 100mg Sandoz
426 Urica Tablet 300mg Sandoz
427 Cerazette Tablet 75 mcg Schering
428 Diane Tablet Schering
429 Exluton Limas Tablet 0,5 mg Schering
430 Triquilar ED Tablet Schering
431 Engelic Tablet Schering
432 Claritin Tablet Schering
433 Celestamine Tablet Schering
434 Ardium HD Tablet 500 mg Servier
435 Bioprexum Tablet 5 mg Servier
436 Coveram Tablet 5/5 mg Servier
437 Coveram Tablet 5/10 mg Servier
438 Stablon Tablet 12.5 mg Servier
439 Arcalion Tablet 200 mg Servier
440 Diamicron MR Tablet 30mg Servier
441 Diamicron MR Tablet 60 mg Servier
442 Proliver Tablet Simex
443 Imunvit plus Tablet Simex
444 Simdrol Tablet 4mg Simex
445 Fucoidan 100 Tablet 100 mg Soho
446 Biocurliv Tablet Soho
447 Valvir Tablet 500 mg Soho
448 Ativan Tablet 1mg Sunti S
449 Ativan Tablet 2mg Sunti S
450 Ceradolan Tablet Takeda
451 Actos Tablet 30mg Takeda
452 Alinamin F Tablet Takeda

169
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


453 Herbesser CD Tablet 100 mg Tanabe
454 Herbesser CD Tablet 200 mg Tanabe
455 Tanapres Tablet 10 mg Tanabe
456 Adona AC Tablet 10 mg Tanabe
457 Aspar K Tablet 300 mg Tanabe
458 Buscopan Tablet 10 mg Tempo
459 Myori Tablet Tempo
460 Glutrop Tablet 1000 mg Tropica Mas
461 Lipitrob Tablet 600 mg Tropicamas
462 Spedifen Tablet 400 mg Zambon
463 THP Generik Tablet 2 mg
464 Estero Tablet 0.625 mg
465 Spiramycin Generik Tablet
466 Combantrin Tablet 125 mg
467 Combantrin Tablet 250 mg
468 Amadiab Tablet 1mg
469 Eye bright Tablet
470 Vitanorm Tablet
471 Retivit Tablet
472 Glaucon Tablet
473 Natrium diklofenac Generik Tablet 25mg, 50 mg Bernofar
474 Citaz Tablet 50mg Dankos
475 Theravask Tablet 5 mg Darya Varia
476 Theravask Tablet 10 mg Darya Varia
477 Bisoprolol Generik Tablet 5 mg Dexa
478 Alprazolam Generik Tablet 0.5mg Dexa
479 Alprazolam Generik Tablet 1mg Dexa
480 Levofloxacin Generik Tablet 500 mg Dexa
481 Canderin Tablet 8mg Dexa Medica
482 Canderin Tablet 16 mg Dexa Medica
483 Farmadral Tablet 10 mg Fahrenheit
484 Virtaz Tablet 400 mg Fahrenheit
485 Feprax Tablet 0,5mg Ferron
486 Zyloric Tablet 100mg Glaxo
487 Allopurinol Generik Tablet 100 mg Hexapharm
488 Allopurinol Generik Tablet 300 mg Hexapharm
489 Acyclovir Generik Tablet 200 mg Kimia Farma
490 Acyclovir Generik Tablet 400 mg Kimia Farma
491 Thrombo Aspilet Tablet Medifarma
492 Concor Tablet 5 mg Merck
493 Maintate Tablet 5 mg Merck
494 Bisovell Tablet 5 mg Novell
495 Pletaal Tablet 100mg Otsuka
496 Xanax Tablet 0.5mg Pfizer
497 Xanax Tablet 1mg Pfizer
498 Ascardia Tablet 80mg Pharos
499 Ascardia Tablet 160mg Pharos
500 Clinovir Tablet 200 mg Pharos
501 Neuromed Tablet 5000 mg Promed
502 Sanprima F Tablet 800/160 mg Sanbe
503 Blopress Tablet 8mg Takeda
504 Blopress Tablet 16 mg Takeda
505 Aspilet Tablet 80 mg UAP
506 Dolofenac Na Tablet Merck
507 Tegretol Tablet CR 200 mg Novartis
508 Berry vision tablet disp Sanbe
509 FDC Tablet Dispersi 30
510 FDC Tablet Dispersi 50
511 FDC Tablet Dispersi 60
512 Triomun Junior Tablet Dispersi 12 mg
513 Triomun Junior Tablet Dispersi 60 mg
514 Triomun Junior Tablet Dispersi 100mg
515 CDR Tablet eff Bayer
516 Zink Care Tablet eff Kalbe Farma
517 Coldizo Tablet isap Soho
518 Fosrenol Tablet Kunyah 500 mg Fahrenheit
519 Voltaren Tablet Retard 100 mg Novartis
520 Voltaren Tablet SR 75 mg Novartis

170
INJEKSI 182
KAPSUL 134
TABLET 522
JUMLAH BOX 838
DRAFT DAFTAR FORMULARIUM
RUMAH SAKIT KELUARGA HUSADA

No. Nama Obat Kemasan Kandungan Farmasi


521 Noprostol Tablet Vagina Novell
522 Claneksi Tablet, Syrup Sanbe
1 Vigamox Tetes Mata 0,5% Alcon
2 Cendo Genta Tetes Mata CENDO
3 Cendo polygran Tetes Mata Cendo
4 Cendo Midriatil Tetes Mata 1% 5ml Cendo
5 Cendo Tropin Tetes Mata 0,5 % Cendo
6 Cendo Timol Tetes Mata Cendo
7 Tonor Tetes Mata 5.00% Cendo
8 Cendo Augentonic MD Tetes Mata Cendo
9 Cendo Statrol Tetes Mata Cendo
10 Cendo Pantocain Tetes Mata 0.5% 5ml Cendo
11 Cendo Pantocain Tetes Mata 2% 5 ml Cendo
12 Vitrolenta Tetes Mata 5 mg Cendo
13 Lentikular Tetes Mata Cendo
14 Cenfresh Tetes Mata Cendo
15 Cravit Tetes Mata Ferron
16 Allegysal Tetes Mata 2% 5 ml Ferron
17 Chloramfenicol Generik Tetes Mata G
18 Tarivid Tetes Mata Kalbe Farma
19 Kemicetine Tetes Mata 0,5% 5 ml Kalbe Farma
20 Clarastill Tetes Mata Kalbe Farma
21 Cationorm Tetes Mata Kalbe Farma
22 Dibekacin Tetes Mata Meiji
23 Flamar Tetes Mata SANBE
24 Sanbe Tears Tetes Mata Sanbe
25 Natacen Tetes Mata
26 Cendo Xytrol Tetes Mata 5 ml
27 Otopain Tetes Telinga Interbat
28 Tarivid Otic Tetes Telinga Kalbe Farma
29 Akilen Tetes Telinga Sanbe
30 Otilon Tetes Telinga Sanbe
31 Forumen Tetes Telinga Sanbe
32 Otozambon Tetes Telinga Zambon
33 Cendo Tobroson MD TM Mini Dose
34 Ichtiyol-Zalf Tube 10% 15 gr Nufarindo
35 Cygest Pesary Vag. Tablet Alpharma
36 Vagistin Ovula Vag. Tablet Combiphar
37 Neo Gynoxa Vag. Tablet Kalbe Farma
38 Albothyl Ovula Vag. Tablet Pharos
39 Trichodazole Plus Ovula Vag. Tablet Sanbe
40 Actrapid HM 100 Vial 100 iu/ml 10 ml Novonordisk
41 Vomizol Dexa Medica
42 Humalog R Eli Lily
43 Renasistin Fahrenheit
44 Lactasid Bayi Sanofi

171
14 Metoclorpramide Generik Injeksi 10mg/2ml Berno 2
47 Simvastatin Generik Tablet 10mg Berno
48 Simvastatin Generik Tablet 20mg Berno
129 Ciprofloxacin Generik Tablet 500 mg Berno
130 Ciprofloxacin Generik Tablet 500 mg Berno
Dexametasone Generik Tablet 0.5 mg Berno
Prednison GeneriK Tablet 5 mg Berno
Clindamycin OGB Capsul 150mg berno
Clindamycin OGB Capsul 300mg berno
82 Natrium diklofenac Generik Tablet 25mg, 50 Bernofar
51 Asam Tranxamat generik Tablet 250 mg Bernofarm
52 Asam Tranxamat generik Tablet 500 mg Bernofarm
98 Cefadroxil Generik Capsul 500mg Bernofarm
99 Cefadroxil Generik Syrup Bernofarm
114 Ampicillin Generik Injeksi 1 gr Bernofarm 1
139 Griseofulvin Generik Tablet 500mg Darya Varia
Metronidazole Generik syrup 125 Darya Varya 10
16 Ondansentron Generik Injeksi 4 mg Dexa
17 Ondansentron Generik Injeksi 8 mg Dexa
26 Captopril Generik Tablet 12,5 mg Dexa
27 Captopril Generik Tablet 25 mg Dexa
28 Captopril Generik Tablet 50 mg Dexa
29 Ramipril generik Tablet 5 mg Dexa 5
30 Bisoprolol Generik Tablet 5 mg Dexa
33 Nifedipin Generik Tablet 10 mg Dexa
55 Clopidogrel Generik Tablet 75 mg Dexa
67 Alprazolam Generik Tablet 0.5mg Dexa
68 Alprazolam Generik Tablet 1mg Dexa
107 Ceftriaxon Generik Injeksi 1 gr Dexa
132 Levofloxacin Generik Tablet 500 mg Dexa
8 Pantoprazol Generik Capsul 20 mg Dexa Medica 3
9 40 mg Dexa Medica 2
35 Candesartan Generik Tablet 8mg Dexa Medica
36 Candesartan Generik Tablet 16 mg Dexa Medica
41 Spironolactone Generik Tablet 100 mg Dexa Medica 10
49 Atorvastatin Generik Tablet 10 mg Dexa Medica
69 Clobazam Generik Tablet 10mg Dexa Medica
97 Amikasin Sulfat Generik Injeksi 250 mg/2 Dexa medica
105 Cefixim Generik Tablet 200 mg Dexa Medica 4
108 Cefotaxim Generik Injeksi 1gr Dexa Medica 3
119 Co - Amoyclav Generik Tablet Dexa Medica 10
120 Meropenem Generik Injeksi 0,5 gr Dexa Medica 3
Gliquidone Generik Tablet Dexa Medica
PTU Generik Tablet 50 mg Dexa medica
1 Antasida Generik Tablet Erela
2 Antasida Generik Syrup 60 ml Erela
85 Piroxicam Generik Capsul 10 mg Esa Indo
86 Piroxicam Generik Capsul 20 mg Esa Indo
CTM Generik Tablet Esa Indo
61 Ambroxol Generik Tablet 30 mg Essa Indo
24 Amlodipine Generik Tablet 5 mg Ethica 20
25 Amlodipine Generik Tablet 10 mg Ethica 20
60 Efedrin HCl Generik Injeksi 50 mg/ml Ethica 1
Metronidazole Generik Infus 500 mg/10Ethica 5
Calsium Gluconas Generik Injeksi Ethica
13 Metoclorpramide Generik Tablet 10 mg Kimia Farma
46 Nor epineprin generik Injeksi 4 mg G
50 Gemfibrozil Generik Tablet 300 mg Kimia Farma
58 Salbutamol Generik Syrup G
65 Diazepam generik Tablet 5mg G
66 Diazepam generik Tablet 10mg G
70 Phenobarbital Generik Tablet 30 mg G
71 Carbamazepin Generik Tablet 200 mg G
75 Paracetamol Generik Tablet 500 mg G
76 Paracetamol Generik Syrup 120 mg/ 5G
77 Paracetamol Generik Drop 100 mg/mlG
96 Gentamycin Generik Injeksi G
100 Cefalexin Generik Capsul 500 mg G
102 Cefuroxim Generik Capsul G
122 Thiamfenicol Generik Capsul 500mg G
123 Chlorampenicol Generik Capsul G
124 Erytromicin Generik Capsul G
125 Erytromicin Generik Syrup G
126 Claritromycin Generik Tablet 250 mg G
127 Azithromycin Generik Tablet Novell
131 Ofloxacin Generik Tablet 400mg Kimia Farma
134 Doxyciclin Generik Capsul 100mg G
135 Doxyciclin Generik Capsul 100mg G
136 Cotrimoxazole Generik Syrup 200/40 m G
137 Cotrimoxazole Generik Tablet 400/80 m G
138 Lincomycin Generik Capsul G
140 Fluconazole Generik Capsul 100 mg G
Pyrantel Generik Tablet 125 mg Kimia Farma
Metronidazole Generik Tablet 500 mg G
PTU Generik Tablet 100mg G
Vitamin B1 Generik Tablet 50mg G
Vitamin B6 Generik Tablet 10 mg G
Vitamin B12 Generik Tablet G
Vitamin B comp Generik Tablet G
Calsium Laktat Generik Tablet Kimia Farma
Chloramfenicol Generik Eye Oint Kimia Farma
Chloramfenicol Generik Tetes Mata G
Acyclovir Generik Cream Kimia Farma
79 Ibuprofen Generik Tablet 400 mg Great
94 Allopurinol Generik Tablet 100 mg Hexapharm
95 Allopurinol Generik Tablet 300 mg Hexapharm
111 Sefpirom Generik Injeksi 1 gr Hexapharm 2
3 Ranitidin Generik Injeksi Hexpharm 5
4 Ranitidin Generik Tablet 150 mg Hexpharm 10
5 Omeprazole Generik Capsul 20 mg Hexpharm
12 Domperidone Generik Syrup Hexpharm
31 Propanolol Generik Tablet 10 mg Hexpharm
32 Propanolol Generik Tablet 20 mg Hexpharm
37 Losartan Generik Tablet 50 mg Hexpharm
42 Citicholine Generik Tablet 500 mg Hexpharm
43 Citicholine Generik Injeksi 250 mg Hexpharm 3
44 Citicholine Generik Injeksi 500 mg Hexpharm 2
78 Paracetamol Generik Infus 1g Hexpharm 20
80 Asam mefenamat Generik Tablet 500 mg Hexpharm
103 Cefixim Generik Syrup 100mg Hexpharm 5
104 Cefixim Generik Syrup 100mg/5 Hexpharm 20
115 Amoxycillin Generik Tablet 250mg Hexpharm
116 Amoxycillin Generik Tablet 500mg Hexpharm 10
Metformin HCl Generik Tablet 500 mg Hexpharm
Metformin HCl Generik Tablet 750 mg Hexpharm
Ketoconazole Generik Hexpharm
117 Amoxycillin Generik Syrup Holi 50
20 Digoxin Generik Tablet 0.25 mg Indofarma
15 Dimenhidrinate Generik Tablet Kimia Farma 2
23 Isosorbidedinitrate Generik Tablet 10 mg Novell
38 Clonidine Generik Tablet 75/150 m Kimia Farma 10
39 Furosemid Generik Tablet 40 mg Kimia Farma 10
40 HCT Generik Tablet 25 mg Kimia Farma 10
56 Salbutamol Generik Tablet 2 mg Kimia Farma 5
57 Salbutamol Generik Tablet 4 mg Kimia Farma 5
59 Efedrin HCl Generik Tablet 25 mg Kimia Farma 5
62 Ambroxol Generik Syrup 60 ml Kimia Farma
63 Glyceril Guaiacolat GenerikTablet Kimia Farma 5
73 Tramadol Generik Capsul 50 mg Kimia Farma 5
113 Ampicillin Generik Tablet Kimia Farma 10
Acyclovir Generik Tablet 200 mg Kimia Farma
Acyclovir Generik Tablet 400 mg Kimia Farma
Chloroquin Generik Tablet 250 mg Kimia Farma
Kina Generik Tablet 500 mg Kimia Farma
Glibenclamid Generik Tablet Kimia Farma
Vitamin C Generik Tablet 50 mg Kimia Farma
Sulfas Ferosus Generik Tablet Kimia Farma
Oxytetracyclin Generik Eye Oint 1% 3.5 gr Kimia Farma
Betamethasone Generik Cream Kimia Farma
Hydrocortison Generik Cream Kimia Farma
Miconazole Generik Cream Kimia Farma
Acyclovir Generik Cream Kimia Farma
64 OBH Generik Syrup Molex ayus
91 Antalgin Generik/Lexagin Tablet 500 mg Molex Ayus
6 Omeprazole Generik Injeksi 40 mg Novel 5
21 Dobutamin injeksi Novel 3
22 Dopamin Giulini Novel
34 Nicardipine Injeksi 10 mg / 1 Novel 1
45 Nimodipin infus 0.2 mg/ml Novel 2
10 Pantoprazol Generik Injeksi 40 mg Novell 3
53 Asam Tranxamat generik injeksi 250 mg novell 3
54 Asam Tranxamat generik injeksi 500 mg novell 5
74 Injeksi 50 mg/ml Novell 5
81 Ketorolac Generik Injeksi 10 mg Novell 3
90 injeksi 25mg/mL Novell 5
93 Injeksi 500 mcg Novell 2
106 Sefoperazon Generik Injeksi 1 gr Novell
109 Ceftazidime Generik Injeksi 1gr Novell 5
110 Ceftizoxime Na Generik Injeksi 1g Novell 2
112 Cefepime Generik Injeksi novell 3
133 Levofloxacin Generik Infus 500 mg Novell 10
141 Fluconazole Generik Infus 100 mg Novell 5
142 Oxytocin injeksi Novell 5
7 Lansoprazole Generik Capsul 30 mg Nulab
11 Domperidone Generik Tablet 10 mg Nulab
18 Ondansentron Generik Tablet 4 mg Nulab
19 Ondansentron Generik Tablet 8 mg Nulab
83 Kalium diklofenak tablet 50 mg Nulab
84 Kalium diklofenak tablet 25 mg Nulab
87 Meloxicam Generik Tablet 7,5mg Nulab
88 Meloxicam Generik Tablet 15mg Nulab
92 Mecobalamin Generik Tablet 500 mcg Nulab
121 Meropenem Generik Injeksi 1 gr Nulab 2
Glimepiride Generik Tablet 1mg Nulab
Glimepiride Generik Tablet 2 mg Nulab
Cetirizine Generik Tablet Nulab
Metil Prednisolon GeneriK Tablet 4 mg Nulab
Metil Prednisolon GeneriK Tablet 8 mg Nulab
Dexametasone Generik Injeksi 0.5 mg Phapros rajawali
No
72 THP Generik Tablet 2 mg
89 Dexketoprofen Tablet
101 Cefachlor Generik Capsul 500 mg
128 Spiramycin Generik Tablet
box 40,000 10

box 80,000 10

botol 7,912 1
box 26,250 5
box 42,000 5
box 8,591 100
box 13,149 100
box 21,418 100
box 55,450 100

box 204,750 30 614,250


box 252,000 30 504,000

box 100,700 100

box 385,035 100


Vial 66,150 1
Box 126,000 30
vial 126,000 1 378,000
box 9,000 30
box 15,000 30
box 500,000 10
botol 11,000 1
box 220,000 2 vial
box 23,364 10
box 20,000 100

box 54,545 5
box 109,091 5
Botol 35,000 1

box 65,000 50
botol 18,000 1

box 33,636 100

botol 3,500 1

box 12,980 100


box 16,000 60
box 18,636 100
box 22,200 100
box 11,636 100
box 7,639 100
box 9,130 100
box 14,327 100
botol 3,446 1
box 9,818 100
box 19,794 50
box 48,395 100
ta
box 50,000 1
box 37,100 1

box 800,000 10
botol 175,000
box 59,000 1 177,000
box 23,000 5
box 63,000 10
box 29,100 5
box 40,909 6
Box 115,000 5
box 80,000 10 160,000

box 41,500 1
box 200,000 2 vial
box 125,000 1 vial
botol 84,000 1
botol 105,000 1
box 25,000 10

box
box

vial 220,000 1 440,000


Daftar Kebutuhan Obat RS. Keluarga Husada

Novell

No Nama Obat Sediaan Dosis Jumlah Kemasan Harga/box isi Total


1 Asam Tranxamat generik injeksi 250 mg 3 box 23,000 5 69,000
2 Asam Tranxamat generik injeksi 500 mg 5 box 63,000 10 315,000
3 Bupivacain injeksi 5mg/ml 2 box 117,500 5 235,000
4 Cefepime Generik Injeksi Ig 3 box 125,000 1 375,000
5 Ceftazidime Generik Injeksi 1gr 5 box 41,500 1 207,500
6 Ceftizoxime Na Generik Injeksi 1g 2 box 200,000 2 400,000
7 Dexketoprofen injeksi 25mg/mL 5 Box 115,000 5 575,000
8 Dobutamin injeksi 3 box 37,100 1 111,300
9 Fluconazole Generik Infus 100 mg 5 botol 105,000 1 525,000
10 Ketorolac Generik Injeksi 10 mg 3 box 40,909 6 122,727
11 Levofloxacin Generik Infus 500 mg 5 botol 84,000 1 420,000
12 Mecobalamin Generik Injeksi 500 mcg 2 box 80,000 10 160,000
13 Oxytocin injeksi 10 IU 5 box 25,000 10 125,000
14 Pantoprazol Generik Injeksi 40 mg 3 box 59,000 1 177,000
15 Sefoperazon Generik Injeksi 1 gr 2 box 95,000 1 190,000
16 Tramadol Generik Injeksi 50 mg/ml 5 box 29,100 5 145,500
Total 4,153,027
Daftar Kebutuhan Obat RS. Keluarga Husada

Hexapharm

No Nama Obat Sediaan Dosis Jumlah Kemasan Harga Isi Harga


1 Domperidone Generik Syrup 5 mg/5ml 20 botol 11,500 1 230,000
2 Amoxycillin Generik Tablet 500mg 10 box 33,636 100 336,360
3 Asam mefenamat Generi Tablet 500 mg 10 Box 16,000 100 160,000
4 Cefixim Generik Box 100mg 10 box 65,000 50 650,000
5 Cefixim Generik Syrup 100mg/5 m 20 botol 18,000 1 360,000
6 Citicholine Generik Tablet 500 mg 2 Box 180,000 30 360,000
7 Citicholine Generik Injeksi 250 mg 3 box 54,545 5 163,635
8 Citicholine Generik Injeksi 500 mg 2 box 109,091 5 218,182
9 Losartan Generik Tablet 50 mg 10 Box 90,909 30 909,090
10 Metformin HCl Generik Tablet 500 mg 10 box 16,500 100 165,000
11 Omeprazole Generik Capsul 20 mg 20 box 11,136 30 222,727
12 Paracetamol Generik Infus 1g 20 Botol 35,000 1 700,000
13 Ranitidin Generik Injeksi 10 box 23,364 10 233,640
14 Ranitidin Generik Tablet 150 mg 10 box 20,000 100 200,000
Total 4,908,634

Onemed

No Nama Obat Jumlah Kemasan Harga Isi Harga


1 Hand Hygiene 36 botol 22,000 1 792,000
Total 792,000
Daftar Kebutuhan Obat RS. Keluarga Husada

Dexa Medica

No Nama Obat Sediaan Dosis Jumlah Kemasan Harga/box Isi Jumlah


1 Pantoprazol Generik Capsul 20 mg 3 box 204,750 30 614,250
2 Alprazolam Generik Tablet 0.5mg 2 box 64,050 100 128,100
3 Alprazolam Generik Tablet 1mg 2 box 98,700 100 197,400
4 Amikasin Sulfat Generik Injeksi 125 mg/2 ml 2 box 83,180 1 166,360
5 Amikasin Sulfat Generik Injeksi 250 mg/2 ml 2 box 138,600 1 277,200
6 Atorvastatin Generik Tablet 10 mg 5 box 78,750 30 393,750
7 Atorvastatin Generik Tablet 20 mg 3 box 126,000 30 378,000
8 Bisoprolol Generik Tablet 5 mg 5 box 66,484 50 332,420
9 Candesartan Generik Tablet 8mg 3 box 204,750 30 614,250
10 Candesartan Generik Tablet 16 mg 3 box 141,750 30 425,250
11 Captopril Generik Tablet 12,5 mg 5 box 8,591 100 42,955
12 Captopril Generik Tablet 25 mg 5 box 13,149 100 65,745
13 Captopril Generik Tablet 50 mg 5 box 21,418 100 107,090
14 Cefixim Generik Tablet 200 mg 4 box 385,035 100 1,540,140
15 Cefotaxim Generik Injeksi 1gr 3 Vial 66,150 1 198,450
16 Ceftriaxon Generik Injeksi 1 gr 2 vial 82,033 1 164,066
17 Clopidogrel Generik Tablet 75 mg 1 box 283,500 30 283,500
18 Co - Amoyclav Generik Tablet 5 Box 126,000 30 630,000
19 Gliquidone Generik Tablet 2 box 90,720 100 181,440
20 Levofloxacin Generik Tablet 500 mg 2 box 22,025 100 44,050
21 Meropenem Generik Injeksi 0,5 gr 3 vial 126,000 1 378,000
22 Nifedipin Generik Tablet 10 mg 5 box 12,313 100 61,565
23 Ondansentron Generik Injeksi 4 mg 5 box 26,250 5 131,250
24 Ondansentron Generik Injeksi 8 mg 5 box 42,000 5 210,000
25 Pantoprazol Generik Capsul 40 mg 2 box 252,000 30 504,000
26 Ramipril generik Tablet 5 mg 5 box 55,450 100 277,250
27 Spironolactone Generik Tablet 100 mg 5 box 100,700 100 503,500
Total 8,849,981

Mengetahui

Keuangan Direktur Utama

Suseno, SE Hj. Yuliana, S.Tr.Keb.,SE.,MARS


Kimia Farma

No Nama Obat sediaan dosis Jumlah kemasan Harga isi Total


1 Acyclovir Generik Tablet 200 mg 3 box 35,289 100 105,867
2 Acyclovir Generik Tablet 400 mg 3 box 51,939 100 155,817
5 Acyclovir Generik Cream 50 tube 3,290 1 164,500
6 Ambroxol Generik Syrup 60 ml 20 botol 3,446 1 68,920
7 Ampicillin Generik Tablet 10 box 48,395 100 483,950
8 Betamethasone Generik Cream 48 tube 1,842 1 88,416
9 Chloroquin Generik Tablet 150 mg 2 box 15,273 100 30,546
10 Clonidine Generik Tablet 75/150 mcg 10 box 18,636 100 186,360
11 Dimenhidrinate Generik Tablet 2 box 12,980 100 25,960
12 Efedrin HCl Generik Tablet 25 mg 5 box 14,327 100 71,635
13 Furosemid Generik Tablet 40 mg 10 box 22,200 100 222,000
14 Glibenclamid Generik Tablet 3 box 16,720 50,160
15 Glyceril Guaiacolat Generik Tablet 5 box 9,818 100 49,090
16 HCT Generik Tablet 25 mg 10 box 11,636 100 116,360
17 Hydrocortison Generik Cream 48 tube 2,915 1 139,920
19 Kina Generik Tablet 500 mg 1 box 61,818 100 61,818
21 Miconazole Generik Cream 24 tube 3,250 1 78,000
22 Oxytetracyclin Generik Eye Oint 1% 3.5 gr 48 tube 2,520 1 120,960
23 Salbutamol Generik Tablet 2 mg 5 box 7,639 100 38,195
24 Salbutamol Generik Tablet 4 mg 5 box 9,130 100 45,650
25 Sulfas Ferosus Generik Tablet 2 Botol 8,168 100 16,336
Fentanyil
26 Tramadol Generik Capsul 50 mg 5 box 19,794 50 98,970
2,419,430

ETHICA
No Nama Obat Dosis Jumlah Kemasan Harga Isi Total
1 Amlodipine Generik Tablet 5 mg 20 box 9,000 30 180,000
2 Amlodipine Generik Tablet 10 mg 20 box 15,000 30 300,000
3 Calcii Gluconas inj injeksi 100 mg/ml 2 box 327273 24 654,546
4 Atropine injeksi 0.25 mg/ml 1 box 181818 100 181,818
5 Efedrin HCl Generik Injeksi 50 mg/ml 1 box 500,000 10 500,000
6 Metronidazole Generik Infus500 mg/1000 ml 5 botol 11,000 1 55,000
6 Oxytocin injeksi 10 IU 1 box 250,000 100 250,000
6 Aminophylline injeksi 24 mg/ml 1 box 135,000 24 135,000
6 Myomergin injeksi 3 box 50,000 10 150,000
6 EPINEPHRINE injeksi 0.10% 1 box 863,636 100 863,636
3,270,000
Total
#REF!
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Daftar Kebutuhan Obat RS. Keluarga Husada

Nulab
No Nama Obat sediaan dosis jumlah Kemasan Harga isi Total
1 Cetirizine Generik Tablet 10 mg 3 box 14,250 50 42,750
2 Dexketoprofen tablet 25 mg 2 box 150,000 50 300,000
3 Domperidone Generik Tablet 10 mg 5 box 36,693 100 183,465
4 Flunarizin tablet 10 mg 2 box 80,000 40 160,000
5 Flunarizine Hcl tablet 5 mg 2 box 50,000 40 100,000
6 Glimepiride Generik Tablet 1mg 5 box 34,549 50 172,745
7 Glimepiride Generik Tablet 2 mg 5 box 66,149 50 330,745
8 Glimepiride Generik Tablet 3 mg 5 box 88,840 50 444,200
9 Kalium diklofenak tablet 50 mg 5 box 17,765 50 88,825
10 Kalium diklofenak tablet 25 mg 5 box 32,183 50 160,915
11 Lansoprazole Generik Capsul 30 mg 5 box 24,570 20 122,850
12 Loratadine Tablet 10 mg 5 box 15,140 50 75,700
13 Mecobalamin Generik Tablet 500 mcg 5 box 70,000 100 350,000
14 Meloxicam Generik Tablet 7,5mg 5 box 31,450 50 157,250
15 Meloxicam Generik Tablet 15mg 5 box 54,500 50 272,500
16 Metil Prednisolon GeneriK Tablet 4 mg 5 box 40,050 100 200,250
17 Metil Prednisolon GeneriK Tablet 8 mg 5 box 53,182 100 265,910
18 Misoprostol Tablet 200 mcg 5 box 150,000 30 750,000
19 Ondansentron Generik Tablet 4 mg 20 box 40,050 10 801,000
20 Ondansentron Generik Tablet 7 mg 19 box 53,182 10 1,010,458
21 Paracetamol sy Botol 120mg 50 Botol 2,350 1 117,500
Total 6,107,063
No Nama Obat Dosis Jumlah Kemasan Harga
1 Amlodipine Generik Tablet 5 mg Ethica 20 box 9,000
2 Amlodipine Generik Tablet 10 mg Ethica 20 box 15,000
3 Calcii Gluconas inj injeksi 100 mg/ml Ethica 2 box 327273
4 Atropine injeksi 0.25 mg/ml Ethica 1 box 181818
5 Efedrin HCl Generik Injeksi 50 mg/ml Ethica 1 box 500,000
6 Metronidazole Generik Infus 500 mg/1000 ml Ethica 5 botol 11,000
6 Oxytocin injeksi 10 IU Ethica 1 box 250,000
6 Aminophylline injeksi 24 mg/ml Ethica 1 box 135,000
6 Myomergin injeksi Ethica 3 box 50,000
6 EPINEPHRINE injeksi 0.10% Ethica 1 box 863,636
Isi Total
30 180,000
30 300,000
24 654,546
100 181,818
10 500,000
1 55,000
100 250,000
24 135,000
10 150,000
100 863,636
3,270,000
Bernofarm

No Nama Obat sediaan dosis jumlah kemasan harga


1 Amoxicillin tablet 250 mg 2 box 35,000
2 Amoxicillin tablet 500 mg 5 box 75,000
3 Ampicillin Generik Injeksi 1 gr 1 box 80,000
4 Asam Tranxamat generik Tablet 500 mg 2 box 180,000
5 Cefadroxil Generik Capsul 500mg 3 box 110,000
6 Cefadroxil Generik Syrup 30 box 8,945
7 Cimetidin tablet 200 mg 2 box 20,000
8 Ciprofloxacin Generik Tablet 500 mg 3 box 70,000
9 Clindamycin OGB Capsul 150mg 2 box 100000
10 Clindamycin OGB Capsul 300mg 2 box 181818
11 Dexametasone Generik Tablet 0.5 mg 3 box 14,000
12 glimepirid tablet 4 mg 2 box 284,294
13 Lidocain 2% Injeksi 2% 1 box 150,000
14 Methylprednisolon Injeksi 125 mg 5 vial 45,000
15 Metoclorpramide Generik Injeksi 10mg/2ml 2 box 40,000
16 Metronidazol tablet 3 box 24,000
17 Natrium diklofenac Generik Tablet 25mg, 50 3 box 23,747
18 Nistatin drop botolo 1 box 220,000
19 Nor ephineprine injeksi 4mg/4ml 2 bos 300,000
20 Prednison GeneriK Tablet 5 mg 3 box 18,000
Paracetamol infus
21 Simvastatin Generik Tablet 10mg 2 box 55,963
22 Simvastatin Generik Tablet 20mg 2 box 111,928
23 Thiamphenicol tablet 500 2 box 120,000
24 Thiamphenicol Syrup 125mg/5 10 Bootol 20,000
Total
isi total
100 70,000
100 375,000
10 80,000
100 360,000
100 330,000
1 268,350
100 40,000
100 210,000
100 200,000
100 363,636
100 42,000
100 568,588
100 150,000
1 225,000
10 80,000
100 72,000
100 71,241
10 220,000
5 600,000
100 54,000

100 111,926
100 223,856
100 240,000
1 200,000
5,155,597
No Nama kemasan harga Jumlah
1 Ecosol Glucose 5% 500 ml 10 botol/box 7000

1 Alprazolam Generik 0.5mg box 64,050


2 Alprazolam Generik 1mg box 98,700
5 Atorvastatin Generik 10 mg box 78,750
6 Atorvastatin Generik 20 mg box 126,000
7 Bisoprolol Generik 5 mg box 66,484
12 Captopril Generik 50 mg box 21,418
10 Clopidogrel Generik 75 mg box 283,500
11 Co - Amoyclav Generik Box 126,000
18 Ramipril generik 5 mg box 55,450
16 Pantoprazol Generik 20 mg box 204,750
17 Pantoprazol Generik 40 mg box 252,000
2 Amoxycillin Generik 500mg box 33,636
10 Metformin HCl Generik 500 mg box 16,500
No Nama Obat Kemasan Dosis Jumlah Kemasan @HARGA ISIAN HARGA
Interbath
1 Acitral Syrup 50 botol 32,000 1 1,600,000
2 Acitral Tablet 5 box 97,500 100 487,500
3 Alco Drop 20 botol 66,750 1 1,335,000
4 Alco + DMP syrup 20 botol 38,250 1 765,000
5 Alco plus Syrup 20 botol 48,000 960,000
6 Ceptik Capsul 100mg 2 Box 645,000 30 1,290,000
7 Ceptik Syrup 100 mg/ 5 5 Botol 87,000 1 435,000
8 Clogin Tablet 75 mg 1 Box 467,600 28 467,600
9 Dazolin infus 5 botol 85,000 1 425,000
10 Diflam tablet 50 mg 5 Box 167,500 50 837,500
11 Erythrin Syrup 10 botol 44,000 1 440,000
12 Gitas plus injeksi 2 box 122,500 5 245,000
13 Inbion Capsul 5 Box 168,000 100 840,000
14 indexon tablet 5 box 56,000 280,000
15 Inerson Cream 3 Tube 65,000 1 195,000
16 Insaar Tablet 50 mg 5 box 346,500 30 1,732,500
17 Interflox Tablet 500mg 3 Box 169,200 12 507,600
18 Interlac Sachet 1 box 279,000 30 279,000
19 Intermic Injeksi 250 mg 1 box 94,500 5 94,500
20 Intermoxil Tablet 500mg 5 Box 325,000 100 1,625,000
21 Interpect Tablet 30 mg 1 Box 130,000 100 130,000
22 Interpril Tablet 5 mg, 5 box 93,600 30 468,000
23 Interpril 10 mg 5 box 139,500 30 697,500
24 Intervask Tablet 5 mg 5 box 201,000 30 1,005,000
25 Intervask 10 mg 5 box 348,000 30 1,740,000
26 Interzinc Syrup 10 botol 33,920 1 339,200
27 Interzol Cream 5 Tube 22,000 1 110,000
28 Interzol tablet 5 box 260,000 1,300,000
29 Intrizin Tablet 3 Box 171,000 30 513,000
30 Invomit Tablet 4 mg 5 box 280,800 18 1,404,000
31 Invomit 8 mg 5 box 425,250 18 2,126,250
32 Ketrobat injeksi 30 mg 2 Box 110,000 5 220,000
33 Ketrobat 10 mg 2 Box 217,500 5 435,000
34 Mefinter Tablet 500 mg 5 Box 185,000 100 925,000
35 Meloxin Injeksi 10 mg /ml 3 Box 140,925 5 422,775
36 Neurobat Forte Injeksi 3 Box 180,000 20 540,000
37 Ossovit Tablet 2 Box 252,000 60 504,000
38 Pamol Syrup 120 mg/5 20 botol 23,000 1 460,000
39 Pamol Drop 20 botol 40,000 1 800,000
40 Pamol Supp 125 mg 1 Box 132,000 12 132,000
41 Pamol Supp 250 mg 1 Box 191,400 12 191,400
42 Pantopump injeksi 5 Vial 148,500 742,500
43 Pantopump tablet 3 box 126,000 378,000
44 Prestrenol Tablet 1 Box 205,000 50 205,000
45 Protop Capsul 20 mg 3 box 149,000 14 447,000
46 Renax Tablet 1 Box 365,000 50 365,000
47 Rycef Injeksi 1 gr 5 Vial 167,000 1 835,000
48 Spiranter Tablet 500mg 1 Box 730,000 100 730,000
49 Theobron Syrup 10 botol 37,400 1 374,000
50 Theobron Caps 2 Box 205,000 100 410,000
51 Thiamycin Capsul 500 mg 2 Box 387,000 100 774,000
52 Thiamycin Syrup 5 botol 35,200 1 176,000
53 Timipen Injeksi 1gr 5 Ampul 328,600 1 1,643,000
54 Tradyl tablet 50 mg 2 Box 192,500 50 385,000
55 Tradyl Injeksi 50 mg/ml 10 Box 97,000 5 970,000
56 Trifed Tablet 2 Box 112,500 100 225,000
57 Trifed Syrup 10 Botol 27,300 1 273,000
58 Trifed Tabklet 3 box 112,500 50 337,500
59 Trifed Syrup 10 botol 27,300 1 273,000
60 Urinter Capsul 400mg 1 Box 470,000 100 470,000
61 Zoter Cream 10 Tube 44,000 1 440,000
62 Eliksir 10 botol 40,950 1 409,500
TOTAL HARGA 40,166,825
Bernofarm

No Nama Obatsediaan dosis jumlah kemasan harga isi total


1 Amoxicilli tablet 250 mg 2 box 35,000 100 70,000
2 Amoxicilli tablet 500 mg 5 box 75,000 100 375,000
3 Ampicillin Injeksi 1 gr 1 box 80,000 10 80,000
4 Asam TranTablet 500 mg 2 box 180,000 100 360,000
5 CefadroxilCapsul 500mg 3 box 110,000 100 330,000
6 CefadroxilSyrup 30 box 8,945 1 268,350
7 Cimetidin tablet 200 mg 2 box 20,000 100 40,000
8 CiprofloxaTablet 500 mg 3 box 70,000 100 210,000
9 Clindamy Capsul 150mg 2 box 100000 100 200,000
10 Clindamy Capsul 300mg 2 box 181818 100 363,636
11 DexametaTablet 0.5 mg 3 box 14,000 100 42,000
12 glimepirid tablet 4 mg 2 box 284,294 100 568,588
13 Lidocain Injeksi 2% 1 box 150,000 100 150,000
14 Methylpre Injeksi 125 mg 5 vial 45,000 1 225,000
15 Metoclorp Injeksi 10mg/2ml 2 box 40,000 10 80,000
16 Metronidatablet 3 box 24,000 100 72,000
17 Natrium d Tablet 25mg, 50 3 box 23,747 100 71,241
18 Nistatin d botolo 1 box 220,000 10 220,000
19 Nor ephineinjeksi 4mg/4ml 2 bos 300,000 5 600,000
20 PrednisonTablet 5 mg 3 box 18,000 100 54,000
21 Simvastat Tablet 10mg 2 box 55,963 100 111,926
22 Simvastat Tablet 20mg 2 box 111,928 100 223,856
23 Thiamphentablet 500 2 box 120,000 100 240,000
24 ThiamphenSyrup 125mg/5 10 Bootol 20,000 1 200,000
Total 5,155,597

Magalat Susp Ferron 25,000 1


Hyperil 5 Tablet 5 mg Ferron 2 box 450,000 60
B Beta Tablet 5 mg Ferron 2 box 178,000 30
Crome Injeksi 50 mg Ferron 1 box 200,000 10
Crome Tablet 10 mg Ferron 1 box 200,000 100
Edotin Capsul 300 mg Ferron botol 75,000 20
Feprax Tablet 0,5mg Ferron 3 box 52,000 30
Feprax Tablet 1 mg Ferron 2 box 79,000 30
Ganin Tablet 300mg Ferron
Mecox Tablet 15 mg Ferron 170,000 20
Ketesse Tablet Ferron 2 Box 400,000 50
Ketesse Injeksi Ferron 3 Box 235,000 5
Fepiram Infus 12gr/60 mFerron box 165,000 1
Dexacef FSyrup Ferron Botol 35,000
Dexacef FCapsul Ferron Box 472,000 60
Ceftum Injeksi 0,5 gr Ferron
Ceftum Injeksi 1 gr Ferron
Sporacid Capsul 100 mg Ferron
Fungatin Drop Ferron
Glumin X Tablet 500 mg Ferron
Glumin X Tablet 750 mg Ferron
Glubose Tablet 50 mg Ferron
Seloxy Kaplet Ferron
Oxypen Tablet Ferron
Biobran Tablet 250 mg Ferron
Cravit Tetes Mata Ferron
Allegysal Tetes Mat2% 5 ml Ferron
Ketricin Tablet Ferron
Ketricin Gel Ferron
Histrin Syrup Ferron
Medixon Injeksi 125 mg Ferron 75,000 1
Medixon tablet 4mg Ferron box 230,000 100
Medixon tablet 16mg Ferron box 170,000 30

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